Budget of Wisconsin

Application for Employment

We are an equal opportunity employer.

denotes a required field

PERSONAL INFORMATION

required Name

Last: First: MI:

required Current Address

Street:

City: State: Zip:

Previous Address

Street:

City: State: Zip:

Email Address:

Application Date

07/31/2010

required Phone Numbers

Home:

Mobile:

Business:
(At least one)

How long at address

Years: Months:

Referred By

required Have you ever applied to, or been employed by Budget of Wisconsin before?

Yes, I have. No, I have not.
If so, when and where?

required Are you legally eligible for employment in the United States?

Yes, I am. No, I am not.

Before you are hired, you will be asked to produce evidence that you are legally eligible for employment.

required Have you been convicted of a crime within the last five years?

Yes, I have. No, I have not.
If yes, what was the crime and date of conviction?

required Is any criminal charge pending against you at this time?

Yes, there is. No, there is not.
If yes, what charge is pending?

Criminal records or pending charges do not constitute an automatic bar to employment and will be
considered only as they relate to the job being applied for.

AVAILABILITY

required Location applying for:

Total hours available per week:

Position desired:

Full Time Part Time

Available for:

Date you can start:

Salary desired:

Hours available:

FROM

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

EDUCATION

High School

Name:

City: State:

Number of Years Attended:

Type of Degree:

Emphasis on:

College

Name:

City: State:

Number of Years Attended:

Type of Degree:

Major/Minor:

Graduate School

Name:

City: State:

Number of Years Attended:

Type of Degree:

Major/Minor:

Business/Technical School

Name:

City: State:

Number of Years Attended:

Type of Degree:

Major/Minor:

List below any special skills/professional licenses you may have to offer.

(Example: typing, steno, personal computer, languages)

EMPLOYMENT HISTORY - LIST FORMER EMPLOYERS STARTING WITH THE MOST CURRENT

required If you are currently employed, may we contact your current employer? Yes No

Current/Most Recent Employer

Name:

Employer Address:

Employer Phone Number:

Supervisor Name and Title:

Reason for Leaving:

From: (mm/yy) Start Salary:

To: (mm/yy) Final Salary:

Start Position:

Final Position:

Previous Employer

Name:

Employer Address:

Employer Phone Number:

Supervisor Name and Title:

Reason for Leaving:

From: (mm/yy) Start Salary:

To: (mm/yy) Final Salary:

Start Position:

Final Position:

Previous Employer

Name:

Employer Address:

Employer Phone Number:

Supervisor Name and Title:

Reason for Leaving:

From: (mm/yy) Start Salary:

To: (mm/yy) Final Salary:

Start Position:

Final Position:

Previous Employer

Name:

Employer Address:

Employer Phone Number:

Supervisor Name and Title:

Reason for Leaving:

From: (mm/yy) Start Salary:

To: (mm/yy) Final Salary:

Start Position:

Final Position:

US MILITARY SERVICE

US Military Service Dates

From: To:

Branch of Service Rank at Discharge

Special Training

REFERENCES - NO FORMER EMPLOYERS OR RELATIVES

Reference 1

Name and Address

Position:

Telephone:

Years Known:

Reference 2

Name and Address

Position:

Telephone:

Years Known:

Reference 3

Name and Address

Position:

Telephone:

Years Known:

PLEASE ANSWER THE FOLLOWING QUESTIONS

Required 1. During the last 12 months, have you used any of the following controlled substances or any
prescription medications without an authorized prescription?

Marijuana

Cocaine/Cocaine Base (Crack)

Speed/Amphetamines/Methemphetamines

Heroin

LSD/Hallucinogens

PCP

Ecstasy

Other (Please list)

required 2. If you have used any of these substances within the last 12 months, when was the last time?

required 3. Have you since quit using controlled substances?

required 4. Within the last 12 months have you been disciplined or terminated from employment for the use of
controlled substances or alcohol?

Required 5. Have you ever been disciplined or terminated by a former employer for:

Absenteeism or tardiness

Theft, unauthorized removal of company property or related offenses

Fighting, assault or related offenses

Insubordination

Violating a safety rule

DRIVERS LICENSE HISTORY RECORD

RESUME

If you have a resume you would like to attach to your application, please use the browse button below.

(.doc, .pdf, or .txt formats accepted)

AGREEMENT

PLEASE READ CAREFULLY BEFORE SUBMITTING ELECTRONICALLY

I understand that this application will be processed as if I have signed it. By submitting this application I acknowledge that I have read and agree to the following:

I certify that the information given by me is true and correct and without any omission.

I understand that any false statement on this application may disqualify me for employment or may lead to my discharge at any time during employment.

I acknowledge that consideration for employment is contingent on the results of a reference and background check. Therefore, I hereby authorize Budget of Wisconsin to (1) investigate the truthfulness of all statements made on this application; (2) contact my former employers and other listed references and any other persons who can verify information; and (3) discuss the results of any investigation with other employees of the company involved in the hiring process. In addition, I give my consent for all contacted persons including former employers to provide information concerning this application and I release each such person from liability for providing information to Budget of Wisconsin. I also authorize Budget of Wisconsin to obtain and review my driving record.

I understand that if I make a written request within a reasonable time of this application, Budget of Wisconsin will inform me of the nature and scope of any investigation conducted.

I understand that all information obtained during pre-employment screening is held by Budget of Wisconsin in the strictest confidence and will not be released to anyone unless Budget of Wisconsin is specifically authorized to do so by me or as required by law.

I further understand that if I am hired, I will not have an employment contract and that my employment and compensation can be terminated with or without notice or cause at any time by me or by Budget of Wisconsin.

Budget of Wisconsin is not responsible for unauthorized interception of materials submitted electronically.

required Yes, I agree with with the above statements.

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Budget of Wisconsin and Rochester, Minnesota