Application For Employment
insite Corporate Headquarters, 207 N. Main Street, Viroqua, WI 54665 608-424-2228
(Pre-Employment Questionnaire) (An Equal Opportunity Employer)
Email address *
Name: *
Your answer
Date: *
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Present Address Street: *
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Present Address City: *
Your answer
Present Address State: *
Your answer
Present Address Zip Code: *
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Permanent Address (If different from Present Address) (street, city, state, zip code)
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Phone (daytime): *
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Phone (evenings): *
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Are you 18 years or older? *
Are you legally eligible for employment in this country? (Proof of eligibility will be required upon employment) *
Position applying for: *
Your answer
Date you can start: *
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DD
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YYYY
Salary desired: *
Your answer
Which location are you interested in applying at? *
What are you available to work? (select all that apply) *
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Indicate what days you are generally available to work: *
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What hours are you available to work? *
Your answer
Do you have a valid driver's license? *
Do you have reliable transportation? *
Insurance is required for many positions. Do you have current auto insurance? *
Education: Name and Location of high school: *
Your answer
Education: Number of years of high school attended: *
Your answer
Education: Did you graduate high school? *
Education: Name and location of college: *
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Education: Number of years of college attended: *
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Education: Did you graduate college? *
Education: Subject studied in college? *
Your answer
Education: Name and location of Trade, Business or Correspondence School:
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Education: Number of years attended Trade, Business or Correspondence School:
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Education: Did you graduate Trade, Business or Correspondence School?
U.S. Military or Naval Services? *
U.S. Military or Naval Services Rank:
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Present membership in National Guard or Services? *
Provide skills and experience applicable to the position you are applying for, such as subjects studied, certifications, licenses, specialized skills, related experience, civic and/or athletic activities, etc. (exclude organizations of which the name indicates race, creed, sex, age, marital status, color or national origin of its members): *
Your answer
Ever employed by insite before? *
Prior position held at insite: *
Your answer
Dates previously employed at insite: *
Your answer
Most recent Employer Name: *
Your answer
Employer Address: *
Your answer
Employer Phone: *
Your answer
Position held: *
Your answer
Work performed: *
Your answer
Dates employed: *
Your answer
Hourly rate: *
Your answer
May we contact this employer? *
If yes, supervisor's name:
Your answer
Reason for leaving: *
Your answer
Name used then, if different:
Your answer
Other previous Employer Name: *
Your answer
Employer Address: *
Your answer
Employer Phone: *
Your answer
Position Held: *
Your answer
Work performed: *
Your answer
Dates employed: *
Your answer
Hourly rate: *
Your answer
May we contact this employer? *
If yes, supervisor's name:
Your answer
Reason for leaving: *
Your answer
Name used then, if different:
Your answer
Other previous Employer Name: *
Your answer
Employer Address: *
Your answer
Employer Phone: *
Your answer
Position held: *
Your answer
Work performed: *
Your answer
Dates employed: *
Your answer
Hourly rate: *
Your answer
May we contact this employer? *
If yes, supervisor's name:
Your answer
Reason for leaving: *
Your answer
Name used then, if different:
Your answer
Reference Number One: (name, relationship, phone number & years known) *
Your answer
Reference Number Two: (name, relationship, phone number & years known) *
Your answer
Reference Number Three: (name, relationship, phone number & years known) *
Your answer
How did you learn about this position? *
Required
 I certify that answers herein are true and complete; furthermore, I understand that misrepresentation or omission of facts in this application or during an interview(s) will be cause for cancellation of consideration for employment or dismissal if employed. I authorize an inquiry to be made on the information contained in this application, and I understand for some positions this may include a thorough background investigation. Upon written request, the nature and scope of this inquiry will be made available to me. Former employers and references named herein are authorized to give information regarding me. They are hereby released from all liability for furnishing such information to insite. I understand that employment is contingent upon a favorable evaluation and/or results of any pre-employment requirements necessary to perform the position applied for. This may include reference checks, criminal background check, a health evaluation form, medical examination, alcohol and controlled substances testing, skills testing, aptitude testing, verification of employment, or other assessment determined necessary. This application for employment shall be considered active for the period of time the position applied for is vacant. Any applicant wishing to be considered for employment beyond this time period should reapply. In addition, a copy of this authorization is as valid as the original and should be recognized as such. *
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