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Application for Employment

Qualified applicants receive equal consideration. No question is asked for the purpose of excluding any applicant due to race, creed, color, national origin, religion, age, sex, handicap, disability, veteran status, marital status, sexual orientation, or any other characteristic protected by law. WE ARE AN EQUAL OPPORTUNITY EMPLOYER. As a condition of employment, you will be required to have an influenza vaccine each “flu season” unless there is a legitimate reason, religious or medical, for declining. You will be required to wear a mask during flu season if not vaccinated.

PLEASE COMPLETE AND SIGN ELECTRONICALLY.
Upload Resume
Max. file size: 50 MB.
Position desired:*
Position Hours:*
- Full Time
- Part Time
Date*
MM slash DD slash YYYY
Name*
First Middle Last
Address*
If you have no reply to this question, please type NA.

Street Address City State / Province / Region ZIP / Postal Code
Telephone*
Email*
EMPLOYMENT HISTORY (List present or most recent employer first)
COMPLETE ADDRESSES ARE NECESSARY for all references: employer and personal.
Employer Name*
If you have no reply to this question, please type NA.
First Last
Employer Address*
If you have no reply to this question, please type NA.

Street Address City State / Province / Region ZIP / Postal Code
Employment Date From*
If you have no reply to this question, please type NA.
Employment Date To*
If you have no reply to this question, please type NA.
Type of work performed*
If you have no reply to this question, please type NA.
Supervisor Name*
If you have no reply to this question, please type NA.
First Last
Supervisor Telephone*
If you have no reply to this question, please type (111)111-1111
Present or last salary
Reason for leaving*
If you have no reply to this question, please type NA.
Employer Name*
If you have no reply to this question, please type NA.
First Last
Employer Address*
If you have no reply to this question, please type NA.

Street Address City State / Province / Region ZIP / Postal Code
Employment Date From*
If you have no reply to this question, please type NA.
Employment Date To*
If you have no reply to this question, please type NA.
Type of work performed*
If you have no reply to this question, please type NA.
Supervisor Name*
If you have no reply to this question, please type NA.
First Last
Supervisor Telephone*
If you have no reply to this question, please type (111)111-1111.
Present or last salary
Reason for leaving*
If you have no reply to this question, please type NA.
Employer Name*
If you have no reply to this question, please type NA.
First Last
Employer Address*
If you have no reply to this question, please type NA.

Street Address City State / Province / Region ZIP / Postal Code
Employment Date From*
If you have no reply to this question, please type NA.
Employment Date To*
If you have no reply to this question, please type NA.
Type of work performed*
If you have no reply to this question, please type NA.
Supervisor Name*
If you have no reply to this question, please type NA.
First Last
Supervisor Telephone*
If you have no reply to this question, please type (111)111-1111
Present or last salary
Reason for leaving*
If you have no reply to this question, please type NA.
Fairhaven has a drug-free workplace program. If you are offered a position, you may be required to submit to a drug and/or alcohol screen. The offer of employment will be rescinded if you have a positive result.
I am aware that Fairhaven has a drug-free workplace and understand that my minor child may be subject to a drug and/or alcohol screen at the time of hire and per Fairhaven policy if employed. I understand that my minor child will be required to receive an influenza vaccine each “flu season” and give my permission for the vaccine to be administrated.*
I am aware that Fairhaven has a drug-free workplace and understand that my minor child may be subject to a drug and/or alcohol screen at the time of hire and per Fairhaven policy if employed.

I understand that my minor child will be required to receive an influenza vaccine each “flu season” and give my permission for the vaccine to be administrated.
I agree to the privacy policy.*
Parent/Guardian Signature (If applicant under 18 years of age)
Date
MM slash DD slash YYYY
Education
High School*
If you have no reply to this question, please type NA.
High School Year*
7
8
9
10
11
12
NA
College
College Year
1
2
3
4
5+
Business or Trade School
Month Attended
Professional Data
Registration for
RN
LPN
CMA
CNA
N/A
State
Date of registration or expiration
Number
Shift Desired*
1st
2nd
3rd
NA
Personal Information
Are you legally authorized to work in the U.S.?*
Yes
No
(Note: you will be required to furnish documents to verify your eligibility for employment in accordance with the Immigration Reform and Control Act and your employment is contingent upon furnishing such documents.)
Are you at least 18 years of age?*
Yes
No
Have you ever been convicted of a crime (felony)?*
Yes
No
(A conviction does not automatically bar you from employment.)
If yes, give details
Do you have any special skills you wish to mention?
If hired, when would you be available?*
If you have no reply to this question, please type NA.
Salary requirements?*
If you have no reply to this question, please type NA.
PERSONAL REFERENCES

COMPLETE ADDRESSES ARE NECESSARY for all references.
Name*
If you have no reply to this question, please type NA.
First Last
Occupation*
If you have no reply to this question, please type NA.
Address
If you have no reply to this question, please type NA.

Street Address City State / Province / Region ZIP / Postal Code
Name*
If you have no reply to this question, please type NA.
First Last
Occupation*
If you have no reply to this question, please type NA.
Address
If you have no reply to this question, please type NA.

Street Address City State / Province / Region ZIP / Postal Code
Name*
If you have no reply to this question, please type NA.
First Last
Occupation*
If you have no reply to this question, please type NA.
Address
If you have no reply to this question, please type NA.

Street Address City State / Province / Region ZIP / Postal Code
Name*
If you have no reply to this question, please type NA.
First Last
Occupation*
If you have no reply to this question, please type NA.
Address
If you have no reply to this question, please type NA.

Street Address City State / Province / Region ZIP / Postal Code
I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind. I agree that the company shall not be held liable in any respect if my employment is terminated because of false statements, answers or omissions made by me in this application. I understand that any misleading or incorrect statements may render this application void, and if employed, may be cause for termination. I understand that a medical examination based on the requirements of the position for which I am being considered may be required, and drug testing may be included as part of the regular pre-employment physical.

I also authorize the companies, schools or persons named above to give any information requested regarding my employment, character, and qualifications. I hereby release said companies, schools or persons from all liability for any damage for issuing this information. In consideration of my employment, I agree to conform to the rules and regulations of this organization. My employment and compensation can be terminated with or without cause, and with or without notice, at anytime, at the option of either my employer or myself.
Type Signature*
Date*
MM slash DD slash YYYY
Reference Check Form

Fairhaven Corporation is required by Wisconsin State law to complete a criminal history check.

The following information is used for reference checking only. All information here will remain confidential. Fairhaven does not discriminate in hiring or employment on the basis of race, color, religious creed, national origin, sex or ancestry or on the basis of age or physical or mental handicap unrelated to ability to perform the work required. No information on this reference check form is intended to secure information to be used for such discrimination. The references will be given every consideration; however, its receipt does not imply that the applicant will be employed.
Name*
First Middle Last
Other Names Used
First Last
Sex
Race
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Consent*
I understand that the above information is true and complete to the best of my knowledge.*
Name*
First Last
Date*
MM slash DD slash YYYY
Reference Request
Applicant Name*
First Last
I authorize the companies, schools or persons named below to give any information requested regarding my employment, character and qualifications. I hereby release said companies, schools or persons from all liability for any damage for issuing this information. In consideration of my employment, I agree to conform to the rules and regulations of this organization. My employment and compensation can be terminated with or without cause, and with or without notice, at any time, at the option of either my employer or myself.
Type Signature*
Date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Have Any Questions?

Name*

Phone*
Email*

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

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262-473-2140
435 West Starin Rd.
Whitewater, Wisconsin 53190

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