Online Employment Application

Pine Valley Community Village fully subscribe to the principles of an Equal Opportunity Employer. Equal access to programs, services, and employment is available to all persons. Those applicants requiring accommodation to the application and/or interview process should contact Chris Glasbrenner of the Human Resource Department at chris.glasbrenner@co.richland.wi.us.

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Your Personal Information
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Best Time To Call You*
Do You Have Access To A Car?*
- Yes
- No
Are You A U.S. Citizen Or Do You Have A Permit, Which Allow You To Work?*
- Yes
- No

Position You're Applying For
Position You're Applying For*
If Applying for Certified Nursing Assistant - Are You Over 18?
- Yes
- No
What Hours Are You Available To Work?*
- AM
- PM
- NOC
Which Days Are You Able to Work?*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
Which Types Of Employment Interest You?*
- Permanent Full Time
- Temporary Full Time
- Permanent Part Time
- Temporary Part Time
If So, How Long?

Education and Training
Select The Highest Grade Or Year You Completed in School*
Do You Have A High School Dipolma Or A GED Equivalency?*
- Yes
- No
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.
Other Training Not Listed Above
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?*
- 25 lbs Or Less
- 50 lbs
- 75 lbs
- 100 lbs Or More
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?
- Yes
- No
Do You Have Difficulty Climbing?*
- Yes
- No
Do You Have Difficulty Standing for Long Periods Of Time?*
- Yes
- No
Do You Have Difficulty Working In Temperature Extremes?*
- Yes
- No
Have You Ever Been Convicted Of Any Violations Other Than Minor Traffic Violations?*
- Yes
- No
For What Have You Been Convicted, When And Where?
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.
Employer 1*
Job Title
Phone
Address
Street Address Address Line 2 City State ZIP Code
Employment Date From
Employment Date To
Please List Your Job Duties
Starting Wage
Ending Wage
Reason For Leaving
Name / Title of Immediate Supervisor
Employer 2*
Job Title
Phone
Address
Street Address Address Line 2 City State ZIP Code
Employment Date From
Employment Date To
Please List Your Job Duties
Starting Wage
Ending Wage
Reason For Leaving
Name / Title of Immediate Supervisor
Employer 3*
Job Title
Phone
Address
Street Address Address Line 2 City State ZIP Code
Employment Date From
Employment Date To
Please List Your Job Duties
Starting Wage
Ending Wage
Reason For Leaving
Name / Title of Immediate Supervisor
Employer 4*
Job Title
Phone
Address
Street Address Address Line 2 City State ZIP Code
Employment Date From
Employment Date To
Please List Your Job Duties
Starting Wage
Ending Wage
Reason For Leaving
Name / Title of Immediate Supervisor

Personal References
Reference 1 - First and Last Name*
First Last
Phone
Email
Address
Street Address Address Line 2 City State ZIP Code
Reference 2 - First and Last Name*
First Last
Phone
Email
Address
Street Address Address Line 2 City State ZIP Code
Reference 3 - First and Last Name*
First Last
Phone
Email
Address
Street Address Address Line 2 City State ZIP Code
List Any Additional Information You Would Like Us To Consider.

Information Authorization
I hereby authorize the Human Resource Department of Pine Valley Community Village to investigate without liability the information supplied by me in my application for employment including academic, occupational, health, police and governmental records. I also authorize listed past employers and personal references to make full response without liability to any inquiries by the Human Resource Department of this long-term care facility in connection with this application for employment. Typed name will be considered as signature.
Signature*
Date*
Email
This field is for validation purposes and should be left unchanged.

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

The Richland Hospital
Richland Medical Center, Ltd
Leading Age Wisconsin
Wisconsin Coalition on Aging
2016-17 Wisconsin Healthcare Guide

Notice of Information
Privacy Policy
Suggestions?
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Name & Location	Date Attended (From and To)	Credits Earned	Major Field	GPA/Base	Degree Conferred and Year

Step 1 of 6

Your Personal Information

Position You're Applying For

Education and Training

Work Experience

Personal References

Information Authorization