Norskedalen Nature & Heritage Center, Inc. Application for Employment

PO Box 235 Norskedalen is an Equal Opportunity Employer

Coon Valley WI 54623 and does not discriminate against any individual in

608-452-3424 any phase of employment in accordance with requirements of local, state, and federal laws.

PERSONAL INFORMATION DATE:

NAME / SOCIAL SECURITY NUMBER
PRESENT ADDRESS
MAILING ADDRESS / E-MAIL
DAYTIME PHONE / ALTERNATE/CELL PHONE

EMPLOYMENT INFORMATION

If hired, can you submit verification of your legal right to work in the United States? ___ Yes ___ No Initial ___

Position Desired:

Date You can Begin Work:

Do you desire: ___ Full-time ___ Part-time ___ Seasonal

Are you willing to work: Weekends ___ Yes ___ No Holidays ___ Yes ___ No Days ___ Yes ___ No

Nights ___ Yes ___ No

Are you able to perform the essential job functions of the position for which you are applying with or without reasonable accommodation? ___ Yes ___ No

Employment Experience: Begin with most current. Please note all information requested

1. Employer / Dates Employed: / hourly rate
/salary:
address / from / Work Performed
telephone number / to
Job title / supervisor
Reason for leaving
2. Employer / Dates Employed: / hourly rate
/salary:
address / from / Work Performed
telephone number / to
Job title / supervisor
Reason for leaving
3.Employer / Dates Employed: / hourly rate
/salary:
address / from / Work Performed
telephone number / to
Job title / supervisor
Reason for leaving

REFERENCES

1 reference / eMPLOYER / phone Number / relationship to applicant:
2 reference

educational Background

Type of school attended / school name & location / did you graduate:
yes/no / diplomA/
degree / major course of study
high school:
circle highest grade completed
9 10 11 12
Post SEcondary

special skills and qualifications

Please note that previous employer information provided may be used and the applicant’s prior employers may be contacted to investigate the applicant’s background.

Have you ever been convicted of any felonies? ___ Yes ___ No If yes, please be prepared to explain.

(conviction of a felony will not automatically disqualify you from employment)

This certifies that the application was completed by me, and that all entries on it and information contained in it are true and complete to the best of my knowledge. I understand that if I am employed, false statements may result in dismissal. I authorize Norskedalen to make an investigation of any facts set forth in this application.

All offers of employment are conditional upon satisfactory reference checks.

Applicant Signature Date

App Created 2/06