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Application
For Employment
NPI is an equal employment opportunity employer dedicated to a policy of nondiscrimination in employment based upon an individual’s race, color, creed, age, sex, national origin, ancestry, disability, arrest or conviction record, sexual orientation, marital status, membership in the National Guard, State Defense Force, or any other reserve component of the military forces of the United States or this state, or use or nonuse of lawful products away from the worksite during nonworking hours. This application will be retained in our active file for six months. If you are offered a job with Northwest Pathways to Independence, Inc., (1) you may, depending on the particular job you are offered, be required to take a physical exam at Northwest Pathways to Independence, Inc.’s expense to determine if you are physically capable, with or without accommodation, of performing the essential functions of the job; and (2) you will be asked to provide your full name, sex, race and date of birth to allow Northwest Pathways to Independence, Inc. to obtain information from the State Crime Information Bureau. Federal law prohibits health care facilities from hiring individuals convicted of abusing, neglecting, or mistreating other individuals in a health care or related setting. Northwest Pathways to Independence, Inc. is required to make a reasonable effort to uncover information about any past criminal prosecutions. This application will be given consideration, but its receipt does not imply that the applicant will be employed. Please contact our Human Resources Department at (715) 723-7570 if you need an accommodation to participate in the application process.
PLEASE FILL OUT ALL BOXES ON APPLICATION FOR SUBMISSION.
POSITION (S) APPLIED FOR / LOCATION PREFERENCE:
LAST NAME: FIRST NAME: M.I.
ADDRESS: CITY STATE ZIP CODE
TELEPHONE NUMBER (S) SOCIAL SECURITY NUMBER
BIRTH DATE
Have you ever been employed with us before? If YES, give date YES DATE NO
Are you currently employed? YES NO
May we contact your present employer? YES NO
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? YES NO
(Proof of citizenship or immigration status will be required upon employment.)
On what date would you be available for work?
Are you available to work: Full time Part time Temporary
Shift available: 1st Shift 2nd Shift Overnights Blocks
We require Personal Care Workers to work some weekend hours. Are you able to meet this requirement? YES NO
Are you currently on “lay off” status and subject to recall? YES NO
You must be 18 years of age or over for employment as a PCW. Do you meet this requirement? YES NO
Do you have a valid driver’s license? YES NO
Is your driver’s license currently revoked or suspended? NO Revoked Suspended
Have you been convicted of a felony within the last 7 years? If Yes, please explain below. NO
(Conviction will not necessarily disqualify an applicant from employment.)
YES, PLEASE EXPLAIN
Were you referred by an employee of NPI? If so, please list referral's name here:
EDUCATION
Elementary Course of Study Years Completed Diploma Received
High School Course of Study Years Completed Diploma Received
College Course of Study Years Completed Diploma Received
Other Course of Study Years Completed Diploma Received
Describe any specialized training, apprenticeship, skills-curricular activities:
EMPLOYMENT EXPERIENCE
Start with your most present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status. Applicants must complete this section even if submitting a resume.
Employer Supervisor
Address
Telephone Salary Employed from to
Job Title
Description of duties
Reason for leaving
MAY WE CONTACT THIS EMPLOYER AS A REFERENCE? YES NO
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OTHER JOB-RELATED EXPERIENCE
Some people gain job-related experience in positions other than as an employee. For instance, an accountant may gain experience as a treasurer of a civic or school organization. Please list and describe any paid or unpaid activities, honors, experience, or training that might aid you in performing the job(s) for which you have applied that have not been listed previously in this application. (You may omit any activities, honors, memberships, or other items that tend to identify your race, sex, religion, national origin, age, disability, or other personal traits that you prefer not to disclose.)
ADDITIONAL DETAILS:
REFERENCES
Do not list former employers or relatives.
Name Address
Telephone Number
Occupation
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DISCLAIMER AND SIGNATURE
IMPORTANT PLEASE READ CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE SIGNING Initials By my signature and initials, I confirm that the information provided in this employment application (and accompanying resume, if any) is true and complete, and I understand that any false information or significant omissions may disqualify me from further consideration for employment, and may be justification for my dismissal from employment, if any discovered at a later date. I agree to immediately notify the company if I should be convicted of a felony, or any crime involving dishonesty or a breach of trust while my job application is pending or during my period of employment, if hired. I authorize any person, school, current employer (except as previously noted), past employer(s), organizations name in this application form (and accompanying resume, if any), and pre-employment screening agencies, to provide the company with relevant information and opinion that may be useful to the company in making a hiring decision, and I release such persons and organizations from any legal liability in making such statements. If offered a job, I five my permission for a pre-employment drug screen and a TB Test, and I consent to the release to the company any medical information, as m may be deemed necessary by the company in judging my capability to perform the essential functions of the work for which I am applying (with or without reasonable accommodation). I understand that if my employment is terminated by the company for dishonesty, breach of trust, criminal acts, or care giver misconduct, the authorities may be notified and I may be criminally prosecuted. I also understand that, if hired, I may not hold other employment, engage in sales, investments, or other activities that create a conflict in interest with the company. I understand that this application does not, by itself, create a contract of employment. I understand and agree that, if fired, my employment is for no definite period of time, and may, regardless of the date of payment of my wages or salary, be terminated at any time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the employee may resign at any time and the employer may discharge the employee at any time with or without cause. It is future 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 authorized executive of this organization.
Signature: Date