APPLICATION FOR EMPLOYMENT and PERSONNEL RECORD Name (Last, First, Middle) * Address * Phone * Email * Are you 18 or older? * Yes No Social Security Number Date of last physical exam Date of last TB test * Have you ever been employed under a different name? * Yes No If yes, list all names. Check all days and times you are willing to work: * Monday days Monday evenings Monday nights Tuesday days Tuesday evenings Tuesday nights Wednesday days Wednesday evenings Wednesday nights Thursday days Thursday evenings Thursday nights Friday days Friday evenings Friday nights Saturday days Saturday evenings Saturday nights Sunday days Sunday evenings Sunday nights Do you possess a valid Wisconsin Driver’s License? * Yes No Do you have reliable transportation? * Yes No Has your Driver’s License ever been suspended or revoked? * Yes No If yes, please explain. Emergency contact name/relationship * Emergency contact phone * Position applied for * Desired salary * Desired hours * Current or most recent employer name/address * Current or most recent employer phone * Current or most recent job title/type of work * Reason for leaving * Dates of employment * Previous employer name/address Previous employer phone Previous job title/type of work Reason for leaving Dates of employment Previous employer name/address Previous employer phone Previous job title/type of employment Reason for leaving Dates of employment Education: Name/address of school * Did you receive a diploma? * Yes No Check the highest grade completed * 6 7 8 9 10 11 12 Are you currently enrolled in a high school completion course? * Yes No Name and Address of University, College or Business School Major or subject Dates of attendance Did you receive a diploma or degree? Yes No List any employment-related education courses, professional and technical qualifications/training Name and address of school or organization Units completed Date completed Currently enrolled? Yes No List licenses or certificates of competence held: Names of professional, trade, business or civic activities of which you are a member and offices held: Reference 1 name/address: * Reference 1 phone number * Reference 2 name/address: * Reference 2 phone number * Reference 3 name/address: * Reference 3 phone number * Do any of your friends or relatives, other than spouse, work here? * Yes No If yes, list name(s) and relationship(s). Are you currently employed? * Yes No If yes, may we contact your present employer? Yes No Are you prevented from lawfully becoming employed in this country due to Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment. * Yes No Are you currently on “Lay-off” status and subject to recall? * Yes No Date available for work * How did you hear about Hilltop? * Advertisement Employment agency Friend Relative Other Why do you think you would be a good applicant for employment at this facility? * Describe any extra-curricular activities and hobbies. I certify under penality of perjury that the above statements are true and correct. I give my permission for any necessary verification. * Yes No Applicant signature/date * CIVIL RIGHTS INFORMATION OPTIONAL — You may decline to complete this portion. Hilltop Affiliates Inc. is required to track the race, ethnicity and gender of its applicants. The following information is voluntary. It is the same information collected on U.S. Census forms. Hilltop uses it to track the race, ethnicity and gender of potential employees to ensure nondiscrimination in hiring. You are not required to complete this portion of the application. This portion of the application will be kept separate and used for tracking purposes only. Gender (Optional) Female Male Ethnicity (Optional) Hispanic/Latino Not Hispanic/Latino Race (Optional) American Indian or Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander White More than one race reCAPTCHA Submit Δ 2020-03-14
