Fillable An equal opportunity employer Application for employment Personal (Dane County Humane Society)

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An equal opportunity employer Application for employment Personal (Dane County Humane Society)

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  • 20 check-boxes
  • 111 other fields

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Revised 04-2017 Page 1
An equal opportunity employer
Application for employment
Date: ____________________
Personal Information
Name_____________________________________________________________________________________
Last First Middle
Address___________________________________________________________________________________
Street City State Zip
Phone______________________________________ Alternate Phone_________________________________
E-mail address______________________________________________________________________________
Position Desired_________________________________
Date you can start____________________________ Salary Desired___________________________________
Are you eligible to accept employment in the USA? Yes [ ] No [ ]
Are you over the age of 18 years? Yes [ ] No [ ]
Have you ever applied to Dane County Humane Society before? Yes [ ] No [ ] If so, when? ______
Have you ever volunteered/worked for Dane County Humane Society before? Yes [ ] No [ ]
When? _________________What was your position? _________________________
Can you perform the essential functions of the position for which you are applying? Yes [ ] No [ ] If no, please
explain. (If you have any questions as to what functions are applicable to the position for which you are
applying, please ask to review the job description.)
__________________________________________________________________________________________
__________________________________________________________________________________________
Revised 04-2017 Page 2
Availability (If employed, I will notify my supervisor in writing, should my availability change.)
***Evenings, weekends, and holidays may be required for some positions. ***
Please indicate the days and times you are available to work.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
From:
To:
Education
Name/Location # Years Attended Degree/diploma received? Subjects Studied
High School
Yes [ ] No [ ]
Type of degree received:
College/University
Yes [ ] No [ ]
Type of degree received:
Trade, Business,
Other
Yes [ ] No [ ]
Type of degree received:
Post-grad,
Continuing Ed.
Yes [ ] No [ ]
Type of degree received:
Work Experience
Please give a complete record of any employment beginning with present or most recent position. Indicate any
change in job title under the same employer as a separate position.
Employer__________________________________________________________________________________
Type of business/organization_________________________________________________________________
Address of business/organization_______________________________________________________________
Your title_________________________________ Reason for leaving_________________________________
Name, title, and phone # of supervisor___________________________________________________________
From (mo/yr)__________to (mo/yr)__________ Full-time__________ or Part-time__________
Beginning rate of pay $__________ per __________ Ending rate of pay $__________ per __________
Your duties:
Revised 04-2017 Page 3
Employer__________________________________________________________________________________
Type of business/organization_________________________________________________________________
Address of business/organization_______________________________________________________________
Your title_________________________________ Reason for leaving_________________________________
Name, title, and phone # of supervisor___________________________________________________________
From (mo/yr)__________to (mo/yr)__________ Full-time__________ or Part-time__________
Beginning rate of pay $__________ per __________ Ending rate of pay $__________ per __________
Your duties:
Employer__________________________________________________________________________________
Type of business/organization_________________________________________________________________
Address of business/organization_______________________________________________________________
Your title_________________________________ Reason for leaving_________________________________
Name, title, and phone # of supervisor___________________________________________________________
From (mo/yr)__________to (mo/yr)__________ Full-time__________ or Part-time__________
Beginning rate of pay $__________ per __________ Ending rate of pay $__________ per __________
Your duties:
Revised 04-2017 Page 4
Employer__________________________________________________________________________________
Type of business/organization_________________________________________________________________
Address of business/organization_______________________________________________________________
Your title_________________________________ Reason for leaving_________________________________
Name, title, and phone # of supervisor___________________________________________________________
From (mo/yr)__________to (mo/yr)__________ Full-time__________ or Part-time__________
Beginning rate of pay $__________ per __________ Ending rate of pay $__________ per __________
Your duties:
References
May we obtain references from the employers named? Yes [ ] No [ ]. If no, name and explain exceptions.
***We reserve the right to ask for additional references. ***
Please answer the following questions:
1. Why do you want to work at Dane County Humane Society and why do you feel that you are a good
candidate for this position?
2. Our mission is “helping people help animals.” What does this mean to you? How would you apply
this to your desired position?
3. What is the extent of your animal handling experience?
Revised 04-2017 Page 5
4. What are your feelings about humane euthanasia?
5. Are you available to work weekends, holidays, and evenings?
I certify that the information contained in this application is true and complete to the best of my knowledge. I
understand that making false statements on this application constitutes grounds for refusing to hire me, or
grounds for dismissing me, if I am hired. In consideration for my employment and my being considered for
employment, I agree to follow DCHS rules and regulations and acknowledge that DCHS may change those
rules and regulations at any time, at its sole discretion, and without prior notice.
I authorize DCHS to contact the references listed above and investigate all statements I made on this
application. I further authorize the above references to give DCHS information concerning my previous
employment and any and all other pertinent information they may have. I authorize DCHS to request and
receive such information, and I hereby release DCHS and said references from any and all liability incurred as a
result of providing such information.
(Signature) (Date)
DCHS is an equal opportunity employer and does not discriminate based on age, race, color, national origin, religion, creed, handicap,
disability, sex, sexual orientation, marital status, physical condition, or any other status protected under applicable federal or state law.
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An equal opportunity employer Application for employment Personal (Dane County Humane Society)

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Completed 9 January 2021

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