Apply for Therapist (Montello, WI)

Complete the online application below. Long answer fields will expand as needed.

Referral and Personal Information

Complete the personal information section from the County employment application.

Referred By Position Applied For * Department Date Available Last Name * First Name * Middle Name Street Address * City * State * ZIP * Home Phone Work Phone May we contact you at work? E-Mail Address * Type of employment acceptable

Full-time Part-time Seasonal LTE

Employment Eligibility

A yes answer does not necessarily disqualify an applicant.

Are you at least 18 years of age? *Employment may be subject to verification that you meet state and federal minimum age requirements. Are you a United States citizen, or do you have papers from the U.S. government permitting you to work? *Verification will be required at time of employment. Are you able to perform all duties listed in the position description, with or without reasonable accommodation? * Have you ever been convicted of a felony? *A yes answer does not necessarily disqualify an applicant. If yes, please explain felony conviction

Education and Training

Education and training beyond high school. Use additional information if more space is needed.

Highest Level Completed

9 10 11 12

Name and Location of High School Graduated?

Education & Training Beyond High School

School #1

Institution 1 - Name and Location Institution 1 - From Institution 1 - To Institution 1 - Major Field of Study Institution 1 - GPA Institution 1 - Degree and Year

School #2

Relevant Coursework Additional Skills and/or Training Professional Licensures/Certifications and Expiration Dates

Driver's License

Complete this section if applicable to the position.

Do you have access to an automobile? Do you have a valid Wisconsin Driver's License? Driver License Number Do you have, or can you make arrangements to obtain, insurance coverage meeting the County's minimum liability insurance requirements on your personal vehicle? List any moving violations within the previous five years If the position requires, do you have a valid Wisconsin Commercial Driver’s License (CDL)? Please list CDL classes and endorsements

Professional References

Please provide three references who can describe your work abilities, qualifications, skills, and/or educational background. Do not list relatives, spouses, or significant others.

Reference #1

Name Telephone Email Address Occupation Nature of Relationship

Reference #2

Name Telephone Email Address Occupation Nature of Relationship

Reference #3

Name Telephone Email Address Occupation Nature of Relationship

Work History - Part A

A yes answer does not necessarily disqualify an applicant.

Have you ever been suspended, terminated, discharged or resigned to avoid being discharged? Have you ever been disciplined for attendance problems in your current or previous employment? Are there any gaps in employment in excess of thirty days? Have you ever been employed by Marquette County? If yes to any of the above, please explain

Work History - Part B

Give a complete record of employment, self-employment, military service, or volunteer experience from the past 10 years. Include older positions if related to the job.

Employer #1

Employer Name Position Title Type of Business Address of Business Reason for Leaving Supervisor Name, Title, and Phone Employment From Employment To Start Salary Ending Salary Hours Per Week Is employer still in business? Description of Duties

Employer #2

Employer #3

Employer #4

Employer #5

Explanation and Referral Source

Use this section for additional explanations or summary information.

Explanation(s) / Summary Information Referral Source Referral Source Detail

Employment Application Affidavit / Information Release

Required for your application to be considered.

I certify that all statements made on or in connection with this application are true, complete and correct to the best of my knowledge and belief. I understand and agree to the affidavit and information release terms. *

I Agree

Name (Printed or Typed) * Signature *

Optional: draw signature below. Typed signature above is still saved.

Typing your name serves as your electronic signature. Date *

Open Records Disclosure (Optional)

This section is optional. Names of final candidates must be open to public inspection under Wisconsin law.

I request that my employment application and all related references and documents remain confidential to the extent allowed by Wisconsin Statutes.

Yes No

Name (Printed or Typed) Signature

Optional: draw signature below. Typed signature above is still saved.

Typing your name serves as your electronic signature. Date

Background Check and Equal Employment Opportunity Information Disclosure Form

Voluntary. This information is maintained as a confidential administrative record and should not be shared with interview panel members.

Last Name First Name Middle Name Position Applied For Date of Birth Are you 40 years of age or older? Maiden Name (If Applicable) Social Security NumberSensitive field. Consider disabling until HR confirms this should be collected online. Sex Race Race - Other Based on the ADA definition, are you an individual with a disability?

Human Services Background Information Disclosure (F-82064)

This Human Services position requires the Wisconsin DHS Background Information Disclosure to be completed online as part of this application. No separate download is needed, because apparently making applicants juggle PDFs was too much ritual even for government.

Notice: A person who provides false information on this form may be subject to forfeiture and sanctions. Completion of this form is used to verify eligibility for employment/service as a caregiver.

Check the box that applies to you

Applicant / Employee Student / Volunteer Contractor Other

Other - Specify

Other Names, including prior to marriage Birth Date Sex

Business Name and Address - Employer (Entity)

Section A - Disclosures

1. Do you have any criminal charges pending against you, including in federal, state, local, military, and tribal courts?If Yes, list each charge, when it occurred or the date of the charge, and the city and state where the court is located.

2. Were you ever convicted of any crime anywhere, including in federal, state, local, military, and tribal courts?If Yes, list each crime, when it occurred or the date of the conviction, and the city and state where the court is located.

3. Has any government or regulatory agency, other than the police, ever found that you committed child abuse or neglect?If Yes, provide an explanation, including when and where the incident occurred.

4. Has any government or regulatory agency, other than the police, ever found that you abused or neglected any person or client?If Yes, explain, including when and where it happened.

5. Has any government or regulatory agency, other than the police, ever found that you misappropriated, improperly took, or used the property of a person or client?If Yes, explain, including when and where it happened.

6. Has any government or regulatory agency, other than the police, ever found that you abused an elderly person?If Yes, explain, including when and where it happened.

7. Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients?If Yes, explain, including credential name, limitations or restrictions, and time period.

Section B - Other Required Information

1. Has any government or regulatory agency ever limited, denied, or revoked your license, certification, or registration to provide care, treatment, or educational services?If Yes, explain, including when and where it happened.

2. Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility?If Yes, explain, including when and where it happened and the reason.

3. Have you been discharged from a branch of the US Armed Forces, including any reserve component?If Yes, indicate year of discharge

4. Have you resided outside of Wisconsin in the last three (3) years?If Yes, list each state and the dates you resided there.

5. If you are employed by or applying for the State of Wisconsin, have you resided outside of Wisconsin in the last seven (7) years?If Yes, list each state and the dates you resided there.

6. Have you had a caregiver background check done within the last four (4) years?If Yes, list the date of each check and the name, address, and phone number of the person, facility, or agency that conducted each check.

7. Have you ever requested a rehabilitation review with the Wisconsin Department of Health Services, a county department, a private child placing agency, school board, or DHS-designated tribe?If Yes, list the review date and the review result.

Name - Person Completing This Form Date Submitted

I have completed and reviewed this form (F-82064, BID) and affirm that the information is true and correct as of today’s date.

Attachments

Additional Documents

Attach PDFs, Word documents, resumes, cover letters, certificates, or other supporting documents. You can select multiple files at one time.

No additional documents selected.

Allowed file types: PDF, DOC, DOCX. Maximum size is 15 MB per file. Files are attached to this application after submission.

I certify that the information provided is true and accurate to the best of my knowledge.