Direct Services Professional Application

Jays Legacy Employment Forms

Employment Application

First Name *

Last Name *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Email Address

What shift(s) are you looking to work? *DaysEveningsOvernightscheck all that apply

Are you looking for full-time or part-time work? *Full-TimePart-Timecheck all that apply

Date Available to Start

Social Security Number0 / 11

Desired Salaryinclude per hour or per year0 / 11

Are you a citizen of the United States? *YesNo

Are you authorized to work in the United States? *YesNo

Have you ever worked for this company? *YesNo

If so, when?

Have you ever been convicted of a felony? *YesNo

If yes, explain here:

High School Education

High School Name

Street Address

City

State/Province

ZIP / Postal Code

Country

Date Started

Date Completed

Did you graduate?YesNo

College Education

College Name

Street Address

City

State/Province

ZIP / Postal Code

Country

Date Started

Date Completed

Did you graduate?YesNo

Degree

ReferencesUse "Add Item" below to add additional references

Reference Name

Note:

References that were previous supervisors are preferred.

Reference Relationship

Reference Email

Confirm Email Address

Reference Phone

Reference Organization

EmployerUse "Add Item" below to add additional employers

Company

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Supervisor Name

Supervisor Email Address

Job Title

Starting Salary

Ending Salary

Responsibilties

Employment Start Date

Employment End Date

Are you currently employed here?YesNo

May we contact this supervisor for a reference?YesNo

Military Service

Branch

Start Date

End Date

Rank at Discharge

Type of Discharge

If other than honorable, explain here:

Supporting Documents

Drag and Drop (or) Choose Files

Resumé, references, etc.

Truthfulness Disclaimer *

I certify that my answers are true and complete to the best of my knowledge. If this application leads to my employment, I understand that false or misleading information in my application or interview may result in my release.

Electronic Signature Disclaimer *

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this application are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Signature *type your full name for electronic signature

Please do not fill in this field.

Background Information Disclosure (BID) – Department of Health Services form F-82064

Completing this form will create a PDF of the form seen here, form instructions here. This form will be used to perform a background check as part of the application process.

PENALTY: Knowingly provided false information or omitting information may result in a forfeiture of up to $1,000 and other sanctions as provided in Wis. Admin. Code § DHS 12.05(4).

Completion of this form is required under the provisions of Wis. Stat. § 50.065. Failure to comply may result in a denial or revocation of your license, certification, or registration, or denial or termination of your employment contract.
Refer to DQA form F-82064A, BID Instructions, for additional information.
Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to prevent incorrect matches.

Background Type *Employee / Contractor (including new applicant)Household member (lives on premises, but is not a client)Applicant for a license, certification, or registration (including continuation or renewal)Other - Specify:Check the box that applies to you

If Other Specify Here

Full Legal NameInclude Middle and Last Name

Any Other Names By Which You Have Been KnownIncluding Maiden Name

Position TitleComplete only if a prospective or current employee or contractor.

Birth Date *

Sex *MaleFemale

Race / Ethnicity *American Indian or Alaskan NativeAsian or Pacific IslanderBlackWhiteOtherCheck ONLY One

If Other Specify Here

Social Security Number *0 / 11

HTML

Home Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Business Name and Address - Employer or Care Provider (Entity) *

A "NO" answer to all questions does not guarantee employment, residency, a contract, or regulatory approval.

Do you have any criminal charges pending against you, including in federal, state, local, military, and tribal courts? *YesNo

If Yes, list each charge, when it occurred or the date of the charge, and the city and state where the court is located. You may be asked to supply additional information, including a copy of the criminal complaint or any other relevant court or police documents.

Were you ever convicted of any crime anywhere, including in federal, state, local, military, and tribal courts? *YesNo

If Yes, list each crime, when it occurred or the date of the conviction, and the city and state where the court is located. You may be asked to supply additional information including a certified copy of the judgement or conviction, a copy of the criminal complaint, or any other relevant court or police documents.

IMPORTANT: Read before completing the following item

Wis. Stat. § 48.981 Abused and neglected children and abused unborn children. (7)(a) CONFIDENTIALITY. "All reports made under this section, notices provided under sub. (3)(bm), and records may be disclosed only to the persons identified in this section.
☑ If you are the employer or prospective employer of the person completing this form and are entitled to obtain this information per the above, check this box.

Has the government or regulatory agency (other than the police) ever found that you committed child abuse or neglect? *YesNo

Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client? *YesNo

If Yes, explain, including when and where it happened.

Has any government or regulatory agency (other than the police) ever found that you misappropriated (improperly took or used) the property of a person or client? *YesNo

If Yes, explain, including when and where it happened.

Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients? *YesNo

If Yes, explain, including credential name, limitations or restrictions, and time period.

Has any government or regulatory agency ever limited, denied, or revoked your license, certification, or registration to provide care, treatment, or educational services? * *YesNo

If Yes, explain, including when and where it happened.

Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility? *YesNo

If Yes, explain, including when and where it happened and the reason.

Have you ever been discharged from a branch of the US Armed Forces, including any reserve component? * *YesNo

If Yes, indicate the year of discharge:

Upload a copy of your DD214, if you were discharged within the last three (3) years.

No file chosen

Have you resided outside of Wisconsin in the last three (3) years? *YesNo

If Yes, list each state and the dates you resided there.

If you are employed by or applying for the State of Wisconsin, have you resided outside of Wisconsin in the last seven (7) years? *YesNo

If Yes, list each state and the dates you resided there.

Have you had a caregiver background check done within the last four (4) years? *YesNo

If Yes, list the date of each check, and the name, address, and phone number of the person, facility, or government agency that conducted each check.

Have you ever requested a rehabilitation review with the Wisconsin Department of Health Services, a county department, a private child placing agency, school board, or DHS-designated tribe? *YesNo

If Yes, list the review date and the review result. You may be asked to provide a copy of the review decision.

Read and initial the following statement.

I have completed and reviewed this form (F-82064, BID) and affirm that the information is true and correct as of today's date. *YesNo

Electronic Signature of Person Completing This Form *Enter full legal name. This will serve as your electronic signature.

Date Submitted *

Please do not fill in this field.

Motor Vehicle Record Release and Authorization Form

Date

First Name *

Last Name *

Email Address *

Drivers License Number *

State/Province

Signature *Electronic Signature. Please type full name to certify this form.

Direct Services Professional Application

Jays Legacy Employment Forms

Employment Application

Background Information Disclosure (BID) – Department of Health Services form F-82064

A "NO" answer to all questions does not guarantee employment, residency, a contract, or regulatory approval.

Motor Vehicle Record Release and Authorization Form

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