Pine Valley Community Village

Richland County, Wisconsin

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Application

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Step 1 of 6

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Your Personal Information

Name*
Address*
Do You Have Access To A Car?*
Are You A U.S. Citizen Or Do You Have A Permit, Which Allow You To Work?*

Position You're Applying For

If Applying For Certified Nursing Assistant - Are You Over 18?
What Hours Are You Available To Work?*
Which Days Are You Able To Work?*
Which Types Of Employment Interest You?*

Education and Training

Do You Have A High School Diploma Or A GED Equivalency?*
Training Beyond High School (College or University)
Name & Location
Date Attended (From and To)
Credits Earned
Major Field
GPA/Base
Degree Conferred and Year
 
Under Credits Earned, indicate Q for Quarter Hours and S for Semester Hours.
Describe any education or training you have had which is not covered above, such as vocational school, correspondence courses, service schools, in-service training or volunteer work which you feel is relevant to the job or jobs for which you are applying. Also include relevant licenses or certificates. (Be Specific.)
Lifting?*
For some positions, it may be required that employees possess certain physical capabilities. Check the appropriate box below, which you feel reflect the physical activities in which you can routinely engage without harm to yourself or fellow employees. Please be assured that a negative answer will not disqualify you from consideration.
Do You Have Difficulty Bending Or Stooping?
Do You Have Difficulty Climbing?*
Do You Have Difficulty Standing For Long Periods Of Time?*
Do You Have Difficulty Working In Temperature Extremes?*
Have You Ever Been Convicted Of Any Violations Other Than Minor Traffic Violations?*
IF THERE ARE ANY EXTENUATING CIRCUMSTANCES OF WHICH WE SHOULD BE AWARE, PLEASE STATE THIS. (Existence of a criminal record does not constitute an automatic bar to employment and your record will be considered only as it may substantially relevant to the job for which you are applying).
*FAILURE TO DISCLOSE CONVICTIONS MAY SUBJECT YOU TO TERMINATION IF HIRED OR ELIMINATE YOU FROM CONSIDERATION IF NOT YET HIRED.

Work Experience

Provide a complete description. This information will be used to determine if your application is accepted. Be specific. Start with your most recent job. BE CERTAIN TO INCLUDE SERVICE IN THE ARMED FORCES. For part-time work, show the average number of hours per month. Indicate any job changes in job title under the same employer as a separate position.
Address
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Personal References

Reference 1 - First And Last Name*
Address

Reference 2 - First And Last Name*
Address

Reference 3 - First And Last Name*
Address

Information Authorization

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This field is for validation purposes and should be left unchanged.

Pine Valley Community Village
25951 Circle View Lane
Richland Center, WI 53581
(608) 647-2138

The Richland Hospital
Leading Age Wisconsin
Wisconsin Coalition on Aging
2021 Wisconsin Healthcare Guide

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Pine Valley Community Village

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