Employment

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Please read this notice before completing application.
If the question does not apply to you, write "N/A" or "Not Applicable".
* Position Applied For (entire name of position):
* Date of Application:
* Name:
Address 1
Address 2
City
State
Zip
* Phone (daytime):
* Phone (evening):
* A. How did you learn about this employment opportunity?
* B. What date are you able to start work?
* C. Do you want to work	Full Time Part Time
* D. If applicable, specify the preferred hours per week or schedule you are available to work:
* E. Are you authorized to work in the USA in the position for which you are applying?	Yes No
* F. Have you previously worked for the Wilder Foundation?	Yes No
If yes, please list all locations and dates:
* G. Is your age at least 18?	Yes No
EMPLOYMENT HISTORY - Begin with your current or most recent employment experience. In addition,
you may include relevant volunteer activity, and/or military experience. Please list all experience during the past ten years.
1. Name of Employer:
Employer's Address:
Give your dates of employment with this employer.
From:
To:
Your position title:
How long in this position?
Briefly describe your responsibilities in this position:
Were you employed on a full-time or a part-time basis?	Full Time Part Time
If part-time, how many hours per week?
Supervisor:
Title:
Phone:
May we contact this person for a reference?	Yes No
Why did you leave this position?
2. Name of Employer:
Employer's Address:
Give your dates of employment with this employer.
From:
To:
Your position title:
How long in this position?
Briefly describe your responsibilities in this position:
Were you employed on a full-time or a part-time basis?	Full Time Part Time
If part-time, how many hours per week?
Supervisor:
Title:
Phone:
May we contact this person for a reference?	Yes No
Why did you leave this position?
3. Name of Employer:
Employer's Address:
Give your dates of employment with this employer.
From:
To:
Your position title:
How long in this position?
Briefly describe your responsibilities in this position:
Were you employed on a full-time or a part-time basis?	Full Time Part Time
If part-time, how many hours per week?
Supervisor:
Title:
Phone:
May we contact this person for a reference?	Yes No
Why did you leave this position?
4. Name of Employer:
Employer's Address:
Give your dates of employment with this employer.
From:
To:
Your position title:
How long in this position?
Briefly describe your responsibilities in this position:
Were you employed on a full-time or a part-time basis?	Full Time Part Time
If part-time, how many hours per week?
Supervisor:
Title:
Phone:
May we contact this person for a reference?	Yes No
Why did you leave this position?
EDUCATION
High School
Name of school:
City:
State:
Diploma or GED received:	Yes No
College/University
Name of school:
City:
State:
Degree received:
Brief description of course of study:
Graduate School
Name of school:
City:
State:
Degree received:
Brief description of course of study:
Vocational/Business/Technical School/Post Graduate/Other
Name of school:
City:
State:
Degree/Certificate/or Diploma received:
Brief description of course of study:
LICENSURE OR CERTIFICATION
(Complete only if required for this position.)
Certification 1
Current Occupational License/Certificate:
Date of Most Recent Certification
Certification State/National License #
Certification 2
Current Occupational License/Certificate:
Date of Most Recent Certification
Certification State/National License #
If operation of a Wilder vehicle, or your own vehicle, is a requirement of this position, your driving record will be reviewed.
Please provide your driver’s license number:
State:
Additional Job Related Information
Please describe any additional job related experiences not previously listed.

Summarize special skills and qualifications acquired from employment, volunteer or other experience.

CRIMINAL BACKGROUND
Have you ever been convicted of a crime?	Yes No
If yes, please state the type of conviction:
(The existence of a criminal record will not automatically disqualify you from the job for which you applied.)
MEDICARE/MEDICAID EXCLUSION
Have you ever been excluded from any federal health care program?	Yes No
If yes, please explain the circumstances and periods of exclusion.

(For certain jobs, Wilder is required to check the list of excluded individuals on the Health and Human Services, Office of the Attorney General website. Being on this list may result in your not being hired, or if hired, may result in termination.)
PLEASE READ CAREFULLY AND EXAMINE YOUR APPLICATION BEFORE SUBMITTING TO SEE THAT YOU HAVE GIVEN AN ANSWER TO EACH AND EVERY APPLICABLE ITEM.
By submitting this application, I certify that the facts set forth in this employment application and/or my resume,
if submitted, are true and complete to the best of my knowledge. I understand that any falsification, omission,
misrepresentation or concealment of information on this application may be sufficient grounds for
disqualification from further consideration for hire or immediate discharge and that the Foundation shall not
be liable in any respect if my employment is so denied or terminated. I authorize the Foundation to verify the
information contained in this application and to investigate my personal or employment history. I also authorize
any former school, employer, person, firm, corporation, credit agency or government agency to give the
Foundation information they may have about me. In consideration of the Foundation’s review of this application
I release the Foundation and all providers of information from any liability as a result of furnishing and receiving
this information. I further agree that, if employed, I will conform my conduct to Foundation rules and understand
that unless otherwise specifically agreed to in writing, my employment can be terminated at any time with or
without cause, and with or without notice, at my option or the option of the Foundation. I understand that no
personnel recruiter, interviewer or other representative of the Foundation other than the President has
authority to enter into any agreement for employment for any specified period of time. I also understand that
this application and any employment manuals or handbooks that may be distributed to me during the
course of my employment shall not be construed as a contract.
	.
	.
	Signature __________________________________________________
	You will be asked to sign this application if you are called in for an interview.
	Date ______________________________________________________
.	.

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E-mail: jobs@wilder.org

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