On-Line Application

Fill out and click the submit button to send to our
Human Resource Department!

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
Zip/Postal Code
Country
Work Phone	--
Home Phone	--
Social Security Number	--
E-mail
Position (s) applied for or type of work Select one Admissions Coordinator Automotive Clinical Secretary Home Based Case Manager Home Based Therapist Cook Development Associate Dining Room Attendant Executive Administrative Assistant Grounds and Facility Housekeeping Staff Housekeeping Supervisor Human Resources Generalist Junior Accountant Licensed Practical Nurse Maintenance Supervisor Payroll Clerk Program Manager Qualified Medical Assistant Recreation Specialist Referral Development Specialist Residential Case Manager Residential Coordinator Residential Therapist Regester Nurse School Paraprofessional Senior Accountant Shift Supervisor Training Coordinator Transition Coordinator Unit Shift Supervisor Youth Counselor Other
Type of employment desired: Full-Time Part-Time Temporary
Hours available to work: 6 a.m. - 2 p.m. 2 p.m. - 10 p.m. 10 p.m. - 6 a.m.
Date you will be able to start work:
Have you ever been employed by Wernle? Yes No If yes give dates (mm/dd/yy):
Have you ever worked under a different name? (include maiden name)
Are you 21 years of age or older? Yes No
Have you been convicted of any crime in the last 7 years? Yes No
If Yes please explain:
How were you referred to Wernle?
Skills and Qualifications
Summarize any job-related training, skills, licenses, certificates, and/or other qualifications:
Educational History
List school name and location, years completed, course of study, and any degrees earned: High School College Technical Training Other
Employment History
Please provide all employment information for your past four employers:
Employer 1 Position held Address Telephone Number (include area code) -- Immediate Supervisor: Title Dates employed (mm/dd/yy) From to Salary Job Summary Reason for leaving:
Employer 2 Position held Address Telephone Number (include area code) -- Immediate Supervisor: Title Dates employed (mm/dd/yy) From to Salary Job Summary Reason for leaving:
Employer 3 Position held Address Telephone Number (include area code) -- Immediate Supervisor: Title Dates employed (mm/dd/yy) From to Salary Job Summary Reason for leaving:
Employer 4 Position held Address Telephone Number (include area code) -- Immediate Supervisor: Title Dates employed (mm/dd/yy) From to Salary Job Summary Reason for leaving:
May we contact the employers above? Yes No
If no, Indicate which employer you do not wish us to contact and why:
Have you ever been discharged or asked to resign from any position? Yes No
If yes, please state the employer and dates of employment.
Which position did you like the best and why?
Which position did you like the least and why?
References
List 3 reference names, telephone numbers, and years known (do not include relatives or employees)
I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either the employer or I can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA. I understand that, as a condition of beginning my employment, I must complete a Criminal History Affidavit, which will be checked and verified by law enforcement officials. I also understand that if I am employed, I will be required to provide satisfactory proof of identity, educational qualifications, a valid driver's license, and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.
By checking this box, I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions. I do not agree to these terms and conditions.