Careers

Employment History

Starting with most recent employer, provide the following information

Next recent

Physical Requirements for Housekeeping, Laundry, and Floor Care Positions

Because our cleaning positions involve continuous physical activity, staff is required to perform the following essential duties:

• Walking or standing during most of shift while emptying trash, dusting, and vacuuming, moving linens and other duties.
• Lift and carry up to 30 pounds while emptying trash or moving linens.
• Push and pull a vacuum exerting up to 15 pounds of force during work shift.
• Bend forward (up to 90 degrees) between 50 to 75 times per hour while dusting, folding, vacuuming, or mopping, etc. in the facility.
• Reach forward and downward to push the vacuum (up to 24 inches) and to dust high and low areas.
• Stand approximately all of work time while performing cleaning, laundry and floor care duties.

Educational Background

Starting with your most recent school attended, provide the following information:

References

List name and telephone number of three business/work/personal references who are not related to you and can be previous supervisors. If not applicable, list three school or personal references who are not related to you.

Background Information Disclosure

Instructions: The Background Information Disclosure form (F-82064) gathers information as required by the Wisconsin Caregiver Background Check Law to help employers and governmental regulatory agencies make employment, contract, residency, and regulatory decisions. Complete and return the entire form and attach explanations as specified by employer or governmental regulatory agency. NOTE: If you are an owner, operator, board member, or non client resident of a Division of Quality Assurance (DQA) facility, complete the BID, F-82064, and the Appendix, F-82069, and submit both forms to the address noted in the Appendix Instructions. CAREGIVER BACKGROUND CHECK LAW In accordance with the provisions of Chapters 48.685 and 50.065, Wis. Stats., for persons who have been convicted of certain acts, crimes, or offenses: 1. The Department of Health Services (DHS) may not license, certify, or register the person or entity (Note: Employers and Care Providers are referred to as “entities”); 2. A county agency may not certify a child care or license a foster or treatment foster home; 3. A child placing agency may not license a foster or treatment foster home or contract with an adoptive parent applicant for a child adoption; 4. A school board may not contract with a licensed child care provider; and 5. An entity may not employ, contract with or, permit persons to reside at the entity. The list of offenses affecting caregiver eligibility that require rehabilitation review is available from the regulatory agencies or through the Internet at http://DHS.wisconsin.gov/caregiver/StatutesINDEX.HTM.

THE CAREGIVER LAW COVERS THE FOLLOWING EMPLOYERS / CARE PROVIDERS (Referred to as “Entities”):

Programs Regulated under Chapter 48, Wis. Stats.

Treatment Foster Care, Family Child Care Centers, Group Child Care Centers, Residential Care Centers for Children and Youth, Child Placing Agencies, Day Camps for Children, Family Foster Homes for Children, Group Homes for Children, Shelter Care Facilities for Children, and Certified Family Child Care.

Programs Regulated under Chapters 50, 51, and 146, Wis. Stats.

Emergency Mental Health Service Programs, Mental Health Day Treatment Services for Children, Community Mental Health, Developmental Disabilities, AODA Services, Community Support Programs, Community Based Residential Facilities, 3-4 Bed Adult Family Homes, Residential Care Apartment Complexes, Ambulance Service Providers, Hospitals, Rural Medical Centers, Hospices, Nursing Homes, Facilities for the Developmentally Disabled, and Home Health Agencies – including those that provide personal care services.

Others

Child Care Providers contracted through Local School Boards

THE CAREGIVER LAW COVERS THE FOLLOWING PERSONS:

• Anyone employed by or contracting with a covered entity who has access to the clients served, except if the access is infrequent or sporadic and service is not directly related to care of the client. • Anyone who is a Child Care Provider who contracts with a School Board under Wisconsin Statute 120.13 (14). • Anyone who lives on the premises of a covered entity and is 10 years old or over, but is not a client (“nonclient resident”). • Anyone who is licensed by DHS. • Anyone who has a foster home licensed by DHS. • Anyone certified by DHS. • Anyone who is a Child Care Provider certified by a county department. • Anyone registered by DHS. • Anyone who is a board member or corporate officer who has access to the clients served.

FAIR EMPLOYMENT ACT

Wisconsin’s Fair Employment Law, Chapters 111.31 - 111.395, Wis. Stats., prohibits discrimination because of a criminal record or pending charge; however, it is not discrimination to decline to hire or license a person based on the person’s arrest or conviction record if the arrest or conviction is substantially related to the circumstances of the particular job or licensed activity.

PERSONALLY IDENTIFIABLE INFORMATION

This information is used to obtain relevant data as required by the provisions set forth by the Wisconsin Caregiver Background Check Law. Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to prevent incorrect matches. For example, the Department of Justice uses social security numbers, names, gender, race, and date of birth to prevent incorrect matches of persons with criminal convictions. The Department of Health Services’ Caregiver Misconduct Registry uses social security numbers as one identifier to prevent incorrect matches of persons with findings of abuse or neglect of a client or misappropriation of a client’s property.

BACKGROUND INFORMATION DISCLOSURE (BID)

Completion of this form is required under the provisions of Chapters 48.685 and 50.065, Wis. Stats. Failure to comply may result in a denial or revocation of your license, certification, or registration; or denial or termination of your employment or contract. Refer to the instructions (F-82064A) on page 1 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.

NOTE:

If you are an owner, operator, board member, or non client resident of a Division of Quality Assurance (DQA) facility, complete the BID, F-82064, and the Appendix, F-82069, and submit both forms to the address noted in the Appendix Instructions.

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

BSG Maintenance, Inc. 253 Stockhausen Ln. West Bend, WI 53095

Section A

ACTS, CRIMES, AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION

SECTION B

OTHER REQUIRED INFORMATION

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

I understand, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a forfeiture of up to $1,000.00 and other sanctions as provided in DHS 12.05 (4), Wis. Adm. Code.

Note

If you are an owner, operator, board member, or non client resident of a Division of Quality Assurance (DQA) facility, complete the BID, F-82064, and the Appendix, F-82069, and submit both forms to the address noted in the Appendix Instructions.

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resumé or job interview. I hereby waive any and all rights and claims I have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.