Employment Application - Society's Assets

Employment Form

Position Applying For(Required)

Specific Position Applying For

Were you previously employed by us?

Yes

If yes, when?

If yes, what was the first and last name you worked under?

Who referred you to Society’s Assets / SAI Home Health?

How did you hear about this position?

Please specify newspaper

Please Specify

Personal Information

First Name(Required)

Middle

Last Name(Required)

Address(Required)

Address 2

City(Required)

State(Required)

ZIP(Required)

Home Phone Number(Required)

Cell Phone Number

E-Mail Address(Required)

Social Security Number(Required)

Attach your resume if available

Accepted file types: txt, rtf, odf, pdf, doc, docx, Max. file size: 2 MB.

Previous Address(es) Within the Last 3 Years

Previous Address 1

Previous Address 2

Previous Address 3

Are you legally eligible for employment in the United States?(Required)

Yes

Do you now or have you ever had any professional credentials, licenses?(Required)

Yes

(i.e. Registered Nurse, Practical Nurse, CNA), and/or specialized training or certificates (i.e. CPR, First Aid)?

Please List

Do you have any arrests whose outcomes are still pending?(Required)

Yes

If yes, please explain

Have you ever been charged and/or convicted of a crime?(Required)

Yes

If yes, please explain

Do you speak any foreign language(s)?(Required)

Yes

If yes, what languages?

Your Availability

Check all that apply – please note some weekend and holiday work may be required if hired

Morning Hours Range From: 5am – 12pm(Required)

never

sometimes

always

Afternoon Hours Range From: 12pm – 6pm(Required)

never

sometimes

always

Evening Hours Range From: 6pm – 12am(Required)

never

sometimes

always

I am available for overnight hours (Hours range from 7pm – 7am)(Required)

never

sometimes

always

Personal References

No family members unless you are their caregiver

Name(Required)

Phone(Required)

Name(Required)

Phone(Required)

Name(Required)

Phone(Required)

Your Education

High School

Years Completed

Diploma Degree

Describe Course of Study

Employment Experience (start with your current or most recent job)

Employer Name

Address

Address 2

City

State

Zip

Title

Date employed from

Date employed to

Reason for Leaving

Supervisor's Name

Phone Number

Employment Experience Two

Employer Name

Address

Address 2

City

State

Zip

Title

Date employed from

Date employed to

Reason for Leaving

Supervisor's Name

Phone Number

Employment Experience Three

Employer Name

Address

Address 2

City

State

Zip

Title

Date employed from

Date employed to

Reason for Leaving

Supervisor's Name

Phone Number

Required Information

For the next ten questions, please check the appropriate box for each question. If you answer yes, please explain in detail the circumstances of the incident(s).

Birth Date(Required)

Have you ever been convicted of a criminal offense by any court?(Required)

Yes

If Yes Explain

Are you out on bail or on your own recognizance still awaiting trial?(Required)

Yes

If Yes Explain

Have you ever been released or discharged from employment or have you ever resigned in order to avoid such release or discharge?(Required)

Yes

If Yes Explain

Have you ever been convicted of any of the following crimes?(Required)

Murder, rape, robbery, violent assault against another, spousal battery, mayhem, sexual battery, crimes against children. If unsure of accurate date- give an approximate date.

Yes

If Yes Explain

Have you ever manufactured, transported, sold or possessed any illegal controlled substance?(Required)

Yes

If Yes Explain

Have you ever committed arson or burglarized an occupied or unoccupied building?(Required)

Yes

If Yes Explain

Have you ever stolen any amount of money, goods or services from an employer?(Required)

Yes

If Yes Explain

Have you ever stolen any item?(Required)

Goods, or money while in a position of trust, or any other act which demonstrated a lack of respect for other’s property?

Yes

If Yes Explain

Have you ever given any false information on any type of employment application or legal document?(Required)

Yes

If Yes Explain

Have you had more than one of the following?(Required)

DUI (Driving Under the Influence) and/or DWI (Driving While Intoxicated) convictions OR a reduction to reckless driving charge in the past 3 years?

Yes

If Yes Explain

Self Identification

This data is for analysis and affirmative action only. Completion of this section is voluntary and will not jeopardize your employment in any manner. All information will remain confidential and will not be included in your personnel file if you are hired for a position with Society’s Assets, Inc. and/or SAI Home Health, Inc. Thank you.

Gender(Required)

Male

Female

No Comment

Ethnic Groups

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races.

Based on the Descriptions above, Choose your Ethnic Group(Required)

Hispanic or Latino

White (Not Hispanic or Latino)

Black or African American (Not Hispanic or Latino)

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)

Asian (Not Hispanic or Latino)

American Indian or Alaska Native (Not Hispanic or Latino)

Two or More Races (Not Hispanic or Latino)

No Comment

Disability

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

Blindness
Autism
Bipolar disorder
Post-traumatic stress disorder (PTSD)
Deafness
Cerebral palsy
Major depression
Obsessive compulsive disorder
Cancer
HIV/AIDS
Multiple sclerosis (MS)
Impairments requiring the use of a wheelchair
Diabetes
Epilepsy
Schizophrenia
Muscular dystrophy
Missing limbs or partially missing limbs
Intellectual disability (previously called mental retardation)

Based on the info above, please check one of the boxes below

YES, I HAVE A DISABILITY (or previously had a disability)

NO, I DON’T HAVE A DISABILITY

I DON’T WISH TO ANSWER

If you feel that you may need an accommodation to perform the essential job duties for which you are applying, please inform the Human Resources Department prior to hire.

Veteran Status

Disabled Veteran: 30% V.A. compensation or discharge because of disability incurred in line of duty.

Veteran of the Vietnam Era

Other Eligible Veteran

No Comment

Employment Verification and Conditions

I certify that the information provided by me on this questionnaire/application is true and complete. Any misrepresentation or omission of the facts will be considered “falsification of documentation”.

I authorize and release from liability for any damage for issuing information the companies, schools, or persons named who may provide information regarding my employment, character, and qualifications.

I understand that some information from this application (name, SSN#, date of birth, etc.) will be released to certain SAI funding sources (i.e. Forward Health) for selected screenings, i.e. The SSA Death Master File, OIG List of Excluded Individuals/Entities (LEIE), and Excluded Parties List System (EPLS).

Confirm and Authorize(Required)

Enter your full name as confirmation

Verification and Reference Check

I have applied for a position with Society’s Assets, Inc. and authorize you to provide SAI with the information requested. I specifically consent to disclosure in accordance with the provisions of the Privacy Act of 1974 and other applicable Federal and State laws.

Name(Required)

Social Security Number(Required)

Other Names Worked Under

Society’s Assets, Inc. and SAI Home Health Care, Inc. are required by the Wisconsin Department of Health Services 2007 Wisconsin Act 172 to disclose certain information from caregiver background checks to consumers.

By my signature, I understand that by law, Society’s Assets and SAI Home Health Care can release certain conviction information to consumers as required by Wisconsin Act 172. I authorize release of this information to any and all consumers for whom I may potentially provide personal care services.

Date(Required)

Sign below:

Employment Form

Personal Information

Previous Address(es) Within the Last 3 Years

Your Availability

Personal References

Your Education

High School

Employment Experience (start with your current or most recent job)

Employment Experience Two

Employment Experience Three

Required Information

Self Identification

Ethnic Groups

Disability

Veteran Status

Employment Verification and Conditions

Verification and Reference Check

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