It is the policy of this facility to provide equal employment opportunities without regard to race, color, religious, sex, national origin, age, disability or any other reason prohibited by law.

If you have lived at the above address less than 12 months, list previous address:



High School:
College:
School of Nursing Special Schooling or training:

(Amount of education considered necessary will vary according to job applied for.)


Professional Licenses and Certifications:

Employment History

List all previous employers for whom you have worked during the past five years, starting with the most recent. Explain any lapses between times when employed.

Employer #1

Employer #2

Employer #3

Employer #4

Employer #5


Military Service Record:

The hiring and re-employment of veterans will be conducted in accordance with applicable state and federal laws and regulations.


I hereby state that the information given by me in this application is true in all respects. I agree that, if I am employed and the information is found to be false in any respect, I will be subject to dismissal without notice at any time.

In making application for employment, I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I understand that the Waunakee Manor reserves the right to require its employees to submit to blood tests or urinalysis for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the facility. I understand that refusal to submit to a urinalysis, blood test or search, when requested to do so, may result in termination of employment.

I understand and agree that if I am offered employment by the Waunakee Manor, it may be required I work weekends and holidays. I also agree that my employment will be for no definite term and that either I, or the Waunakee Manor, will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice and that this relationship can only be modified in writing and signed by the Administrator.

I hereby authorize my former employers to release information pertaining to my work record, my work habits, and my work performance while in their employ.