Application For Employment

Please answer all questions. Resumes are not a substitute for a completed application.

We are an equal opportunity employer. Applicants are considered for positions without regard to race, religion, sex, national origin, age, disability, or any other category protected by applicable federal, state, or local laws.

THE SHEBOYGAN SURGERY CENTER IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE SHEBOYGAN SURGERY CENTER OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE.

Position Applying For:

Name:

Phone: Cell Phone or Alternate #:

Email:

Present Address
Street, Apt. and/or Unit Number:
City: State: Zip:

How Long Have You Lived At This Address?: Years/Months

Other Address
Street, Apt. and/or Unit Number:
City: State: Zip:

How Long Have You Lived At This Address?: Years/Months

Desired Salary/Hourly Rate:

If under the age of 18, can you produce the necessary work certificate at the time of employment?
Yes No

Type of employment desired? Full-time Part-time

Are you willing to work overtime? Yes No

Date on which you can start work if hired:

Have you previously applied for employment with the Sheboygan Surgery Center? Yes No

If Yes, when and where did you apply?

Have you ever been employed by the Sheboygan Surgery Center? Yes No

If Yes, provide dates of employment, location, and reason for separation from employment.

INSTRUCTIONS FOR ANSWERING THE NEXT TWO QUESTIONS:
All applicants: Do not include convictions that were sealed, eradicated, erased, annulled by a court, or expunged, or convictions that resulted in referral to a diversion program.

Arizona, Colorado, District of Columbia, Illinois, Kansas, Minnesota, Missouri, Montana, Nevada, Rhode Island, South Carolina, and Utah applicants: Do not respond to the second question regarding arrests.

California applicants: Do not include misdemeanor marijuana-related convictions that are more than two (2) years old or misdemeanor convictions for which probation was successfully completed or otherwise discharged and the case was judicially dismissed.

Connecticut applicants: You are not required to disclose the existence of any arrest, criminal charge, or conviction, the records of which have been erased. Criminal records subject to erasure are records pertaining to a finding of delinquency or the fact that a child nolled (not prosecuted), a criminal charge for which the person was found not guilty, or a conviction for which the offender received an absolute pardon. Any person whose criminal records have been erased is deemed to have never been arrested within the meaning of the law as it applies to the particular proceedings that have been erased, and may so swear under oath.

District of Columbia and Washington applicants: Limit any response to the past ten (10) years.

Hawaii applicants: Do not answer the following two questions.

Indiana applicants: Regarding arrests limit your response to pending charges for felonies and class A misdemeanors that are less than one (1) year old.

Massachusetts applicants: Limit any response regarding misdemeanor convictions to the last five (5) years and to those which were not a first offense for drunkenness, simple assault, speeding, a minor traffic violation or disturbing the peace. Applicants with a sealed record on file with the Massachusetts Commissioner of Probation may answer “No Record” with respect to: 1) all inquiries relating to prior convictions or arrests; 2) misdemeanor convictions older than five (5) years; and 3) first time convictions for simple assault, drunkenness, speeding, minor traffic violations or disturbing the peace.

Michigan applicants: Regarding arrests, limit your response to felony arrests awaiting conviction or dismissal.

New York applicants: All pending arrests or criminal accusations must be disclosed. You are not required to disclose arrests or criminal accusations that resulted in criminal actions or proceedings which were terminated in your favor. Do not disclose criminal actions or proceedings that were sealed or classified as youthful offender adjudications. An ex-offender who is denied employment actions or proceedings that were sealed or classified as youthful offender adjudications. An ex-offender who is denied employment may, upon written request receive a statement of the reason(s) for denial within thirty (30) days of the applicant’s request for such information.

North Dakota and Oregon applicants: Regarding arrests, limit your response to pending charges that are less than one (1) year old.

Utah applicants: Limit any response to felony convictions only. Do not respond to the second question regarding arrests.

Have you ever plead guilty or no contest to, or been convicted of any criminal offense other than the applicable exceptions listed above? Yes No

CRIMINAL OFFENSES ONLY: If you answered Yes, to either of the above two questions, please provide the date(s) and explain in accordance with the above instructions so that individual circumstances can be considered.

Criminal convictions or arrests will not automatically disqualify an applicant from a particular job. Sheboygan Surgery Center will consider the nature of the crime, its seriousness, the substantial relation to the position’s functions and qualifications, the number of occurrences, the applicant’s age at the time of the crime, the time elapsed's since the crime, the applicant’s entire work and educational history, employment references and recommendations, and the business necessity of any exclusion when required by law.

Have you ever initiated an act of violence in the workplace? Yes No

If Yes, please provide the date(s) and explain so that individual circumstances can be considered.
(A “Yes” answer will not necessarily disqualify you from employment.)

List all special technical skills that you feel qualify you for the job for which you are applying (For example, computer programming/language, software, equipment operation, special tools or machines, etc.)

Education

School Name and Location:

City: State:

Course Of Study:

Graduate? Yes No

Degree/Major:

High School: Yes No # of Years Completed:

College: Yes No # of Years Completed:

Bus./Tech/Trade Or Post College: Yes No # of Years Completed Post College:

Honors Received

Work Experience
Please list the names of your presend and/or precious employers in chronological order with present or last employer listed first. Account for all periods of time including any period of unemployment. If self-employed, supply firm name and business references. You may include any verifiable work performed on a volunteer basis, internships, or military service. Your failure to completely respond to each inquiry may disqualify you for consideration from employment.

Employer 1

Name:

Address:

Type of Business:

Phone:

Dates Employed From: To:

Job TItle:

Job Duties

Supervisors Name: May We Contact? Yes No

If No, Why Not?

Wages Start: Final:

Reason For Leaving:

What will this employer say was the reason your employment terminated?

How much notice did you give when resigning?

If none, explain

Employer 2

Name:

Address:

Type of Business:

Phone:

Dates Employed From: To:

Job TItle:

Job Duties

Supervisors Name: May We Contact? Yes No

If No, Why Not?

Wages Start: Final:

Reason For Leaving:

What will this employer say was the reason your employment terminated?

How much notice did you give when resigning?

If none, explain

Employer 3

Name:

Address:

Type of Business:

Phone:

Dates Employed From: To:

Job TItle:

Job Duties

Supervisors Name: May We Contact? Yes No

If No, Why Not?

Wages Start: Final:

Reason For Leaving:

What will this employer say was the reason your employment terminated?

How much notice did you give when resigning?

If none, explain

Please explain fully all gaps in your employment history in excess of one month.

Have you ever been terminated or asked to resign from any job? Yes No
If Yes, how many times?

Has your employment ever been terminated by mutual agreement? Yes No
If Yes, how many times?

Have you ever been given the choice to resign rather than be terminated? Yes No
If Yes, how many times?

If you answered Yes to any of the above three questions, please explain the circumstances of each occasion.

References
Please list the names of additional work-related references we may contact. Individuals with no prior work experiences may list school or volunteer-related references.

Reference 1

Reference Name: Position:

Company: Phone:

Work Relationship: (i. e. supervisor, co-worker)

Reference Email:

Reference 2

Reference Name: Position:

Company: Phone:

Work Relationship: (i. e. supervisor, co-worker)

Reference Email:

Applicant Certification
I understand and agree that if driving is a requirement of the job for which I am applying, employment and/or continued employment is contingent on possessing a valid driver’s license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside. I understand that the Sheboygan Surgery Center may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Sheboygan Surgery Center has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that all employees of the location, pursuant to the Sheboygan Surgery Center’s policy and federal, state, and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs. If employed, I understand that the taking of alcohol and/or drug tests is a condition of continual employment and I agree to undergo alcohol and drug testing consistent with the Sheboygan Surgery Center's policies and applicable federal, state, and local law. If employed by the Sheboygan Surgery Center, I understand and agree that Sheboygan Surgery Center, to the extent permitted by federal, state, and local law, may exercise its right, without prior warning or notice, to conduct investigations of property (including, but not limited to, files, lockers, desks, vehicles, and computers) and, in certain circumstances, my personal property. I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement, as well as an agreement to arbitrate. I certify that all the information on this application, my resume, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal. SHEBOYGAN SURGERY CENTER IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE SHEBOYGAN SURGERY CENTER OR I MAY TERMINATE THE EMPLOYEMENT RELATIONSHIP AT ANY TIME, DOR ANY REASON, WITH OR WIHTOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTTIE OF THE SHEBOYGAN SURGERY CENTER IS AUTHORIZED TO ENTER INTO AN AGREEMENT – EXPRESS OR IMPLIED – WITH ME OR ANY APPLICANT FOR EMPLOYEMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE SHEBOYGAN SURGERY CENTER. IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE SHEBOYGAN SURGERY CENTER, AND I UNDERSTAND THAT THE SHEBOYGAN SURGERY CENTER HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL. I authorize the Sheboygan Surgery Center or its agents to confirm all statements contained in this application and/or resume as it relates to the position I am seeking and to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation. I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, claims charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Sheboygan Surgery Center and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information. If hired by this Sheboygan Surgery Center, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Sheboygan Surgery Center. I also understand this Sheboygan Surgery Center employs only individuals who are legally eligible to work in the United States.

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYEMENT AFTER THAT TIME, YOU MUST REAPPLY. I CERTIFY THAT ALL OF THE INFORMATON THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE.

Applicant Signature Date

If the applicant is a minor, the foregoing release and consent must be signed by the applicant’s parent or legal guardian. Signature by the applicant’s parent or legal guardian constitutes acknowledgement by the applicant and the parent or legal guardian that the Sheboygan Surgery Center, to the extent permitted by federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate test results to Sheboygan Surgery Center personnel who need to know, the applicant, and the applicant’s legal guardian.

Parent/Legal Guardian Date
Witness Date

UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR, POLYGRAPH, OR SIMILAR TEST, AN EMPLOYER WHO VIOLATES THIS LAW IS GUILT OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100. I have read and understand the above statement.

Applicant Signature Date

UNDER MASSACHUSETTS LAW, IT IS UNLAWFUL FOR AN EMPLOYER TO REQUIRE OR TO ADMINISTER A LIE DETECTOR, POLYGRAPH OR SIMILAR TEST AS A CONDITION OF EMPLOYEMENT OR CONTINUED EMPLOYMENT.

FEDERAL AND/OR STATE LAW MAY PROHIBIT THE USE OF LIE DETECTOR, POLYGRAPH OR SIMILAR TEST AS WELL.

THIS APPLICATION MAY NOT BE APPLICABLE FOR ALL INDUSTRIES.

3141 Saemann Avenue • Sheboygan, WI 53081 (920) 783-5000 • www.sheboygansurgerycenter.com

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