Employment | Touchstone Living Care West Bend

First Name *

Middle Initial *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Position Applied For *

Available Start Date *

Desired Salary *

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Are you a legal U.S. Resident employable in the United States? *

Have you previously been employed by Touchstone Living Care? *

If yes, give dates

Touchstone of West Bend provides care for our residents twenty-four hours a day, seven days per week. All staff members are required to work weekends and holidays on a rotating basis. You may also be asked to fill in for absent co-workers on an on-call basis. Are you available for work under these conditions? *

List your employers starting with your present or most recent.

Employer Information #1

Employer Name *

Employer Address *

Supervisor's Name *

Employment Dates *

Job Title *

Starting Salary *

Ending Salary *

Reason for Leaving *

List Job Duties and Responsibilities *

May we contact this employer? *

+ Employer Information #2

Employer Name

Employer Address

Supervisor's Name

Employment Dates

Job Title

Starting Salary

Ending Salary

Reason for Leaving

List Job Duties and Responsibilities

May we contact this employer?

+ Employer Information #3

Employer Name

Employer Address

Supervisor's Name

Employment Dates

Job Title

Starting Salary

Ending Salary

Reason for Leaving

List Job Duties and Responsibilities

May we contact this employer?

List any job or volunteer experience that you feel qualifies you for this position *

Highest level of education completed? *

School Name

School Address

Do you have certification (DHS 83 approval number course) in any of the following: (Check all that apply)

Do you have any other certifications?

Do you have any restrictions that would prohibit you from performing the duties required for this position, or are you in need of any special accommodations? *

If Yes, Explain

A criminal background check is required by the State of Wisconsin, the results of which may prohibit employment under State of Wisconsin DHS 83 regulation. By DHS 83 regulation, all employees are required to be at least 18 years of age.

Have you ever been convicted of a crime or felony? *

If Yes, Please Give Convictions and Dates

Please List 3 Professional References:

Reference #1

Name *

Relationship *

Company *

Phone Number *

Reference #2

Name *

Relationship *

Company *

Phone Number *

Reference #3

Name *

Relationship *

Company *

Phone Number *

Disclaimer

Touchstone Living Care of West Bend operates under the philosophy of non-discrimination for all employees regardless of race, origin, color, religion, gender, marital status, sexual preference, veteran status, or disability. Employment decisions will be made on the basis of competency to state or national licensure and/or certification. A criminal background check is required by the State of Wisconsin, the results of which may prohibit employment under State of Wisconsin DHS 83 regulation. By DHS 83 regulation, all employees are required to be at least 18 years of age.

I certify that my answers are true and complete to the best of my knowledge. I authorize Touchstone Living Care of West Bend to investigate this information by contacting my present or former employers and listed references.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
By typing my name below I agree to this disclaimer, and acknowledge that all answers given here in, are true statements.

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