APPLICATION FOR EMPLOYMENT:

Positive Alternatives Inc.

603 Terrill Road                                                                                                                    Resident Counselor

Menomonie, WI  54751                                                                                                       Volunteer/Practicum

(715) 235-9552                                                                                                                 

                                                                                                                                     Other

(PLEASE PRINT)

If you are under 18 years of age, can you provide required proof of your eligibility to work?

 Yes               No

Do you have reliable transportation, valid driver’s license, and insurance?

  Yes                    No

Are you currently employed?

  Yes               No

May we contact your present employer?

  Yes               No

Have you ever applied to this agency?

  Yes              No      If so, when? ___________________________________________

On what date would you be available to work? ____________________________________

How many hours/week do you prefer to work?

3-5     5-10       10-18       19-27     r  28-36

Have you lived in Wisconsin since your 18^th birthday?

 Yes                No

If no, what other states have you lived in since your 18^th birthday? _____________________________

Have you been convicted of a felony within the last 7 years?

 Yes               No

            Conviction will not necessarily disqualify an applicant from employment.

If yes, please explain.

____________________________________________________________________________________________________________________________________________________________________

Education

Skills

Please indicate those areas in which you have had training or experience, including any volunteer or community service work.

Briefly describe any field work experience associated with academic courses, apprenticeship programs, on-the-job training, or teaching experience, etc.

____________________________________________________________________________________________________________________________________________________________________

Employment Experience

Interests and Hobbies

Describe any interests, hobbies, skills, organized athletics, recreational programs, or activities that would be of interest to adolescents. _____________________________________________________

____________________________________________________________________________________________________________________________________________________________________

Motivation Statement

Briefly describe why you wish to work for our agency.  Please state what you hope to “gain from” and “give to” this agency.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

State any additional information you feel may be helpful to us in considering your application.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

References

Emergency Contact Person

Name: _____________________________________

Address: ___________________________________

Phone: _____________________________________

Applicant’s Statement

I verify that answers given herein are true and complete to the best of my knowledge.  I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days.  Any applicant wishing to be considered for employment beyond this period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “and will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause.  It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.  I understand, also, that I am required to abide by all rules and regulations of the employer.

             ___________________________________                          ____________________

                         Signature of Applicant                                                               Date

APPLICANT: DO NOT REMOVE THIS SHEET

REQUEST FOR RACIAL AND ETHNIC DATA

The information on this page is not part of the regular application form.  It is requested solely for the purpose of determining compliance with federal civil rights laws.  Your response will not affect consideration of your application.  By providing this information you will assist us in assuring that this program is administered in a nondiscriminatory manner.

Completion of this form is voluntary; failure to respond will in no way affect our review of your application.

The information requested on this detachable section is covered by the provisions of the Privacy Act.

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Date of Birth: _______________________________

Instructions:  Please categorize yourself by placing an “X” next to the proper category.

  Male              Female

Black, not Hispanic origin (a person having origins in any of the Black racial groups of Africa).

Hispanic (a person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin regardless of race).

American Indian or Alaskan Native (a person having origins in any of the original peoples of North America and who maintains cultural identifications through tribal affiliation or community recognition).

White not of Hispanic origins (having origins in any of the original people of Europe, North America, or the Middle East).

Asian                        Other

Disabled-Disability means any condition or characteristic that renders a person disabled.  A disabled person is one that 1) has a physical, sensory, or mental impairment which substantially limits one or more major life activities, 2) has a record of such, 3) is regarded as having a disability –WI Human Rights Act.

I prefer not to respond.