Job Application Form

Name*

First

Last
Address

Street Address

Address Line 2

City

State

ZIP Code
Phone
Email
Position Desired*
Applying for:
- Neillsville
- Woodville
- Phillips

Education
School 1 Name
Years Completed
Completed?
- Yes
- No
Degree Name?
School 2 Name
Years Completed
Completed?
- Yes
- No
Degree Name?
Additional Education & Certifications
Attendance
Is there anything that would interfere with your regular attendance and punctuality if you were offered a job with the company?
- Yes
- No
Please explain:

References
Reference 1 Name
Title
Phone
Relationship
Reference 2 Name
Title
Phone
Relationship
Reference 3 Name
Title
Phone
Relationship

Employment History
Employer 1 – Company Name
Job Title
Address

Street Address

Address Line 2

City

State

ZIP Code
From
To
Supervisor Name
Phone
Hourly Rate (start – finish)
Reason for Leaving
May we contact this employer?
- Yes
- No
Employer 2 – Company Name
Job Title
Address

Street Address

Address Line 2

City

State

ZIP Code
From
To
Supervisor Name
Phone
Hourly Rate (start – finish)
Reason for Leaving
May we contact this employer?
- Yes
- No
Employer 3 – Company Name
Job Title
Address

Street Address

Address Line 2

City

State

ZIP Code
From
To
Supervisor Name
Phone
Hourly Rate (start – finish)
Reason for Leaving
May we contact this employer?
- Yes
- No

Voluntary Self-Identification of Disability
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability.
Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.
Disabilities include, but are not limited to:
- Blindness
- Autism
- Bipolar disorder
- Post-traumatic stress disorder (PTSD)
- Deafness
- Cerebral palsy
- Major depression
- Obsessive compulsive disorder
- Cancer
- HIV/AIDS
- Multiple sclerosis (MS)
- Impairments requiring the use of a wheelchair
- Diabetes
- Epilepsy
- Schizophrenia
- Muscular dystrophy
- Missing limbs or partially missing limbs
- Intellectual disability (previously called mental retardation)
Please check one of the boxes below:
- Yes, I have a disability.
- No, I don’t have a disability.
- I do not wish to answer.
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

PARTNER WITH OEM | 715-698-2111

Job Application

Step 1 of 8

Education

Attendance

References

Employment History

Skills

Signature

Voluntary Self-Identification of Disability

Voluntary Self-Identification Survey Form Applicant – Affirmative Action Employer

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