Careers Form

* = Required Information

APPLICATION FOR EMPLOYMENT

Equal access to program, services and employment is available to all persons. Those applicants requiring accommodations to the application and/or interview process should contact a representative of the personnel department.

PLEASE PRINT

Position(s) applied for

Date of Application *

Type of employment desired

Full-Time

Part-Time

Temporary

Seasonal

Educational Co-Op

Licensure Number (if applicable)

Expiration Date

CPR Cert. Expiration Date (if applicable)

Name

Last Name *

First Name *

Middle Name*

Address

Street *

City *

State

Zip Code

Telephone Number *

Social Security Number

Driver's License Number (if job related)

State

Email *

Date available to work

Can you before employment submit verification of your legal right to work in the United States?

Yes

Have filed an application here before?

Yes

Date

Have you been employed here before?

Yes

Please give dates

May we contact you at work?

Yes

Work number and best time to call

Are you on a lay-off or subject to recall?

Yes

Are you able to meet the attendance requirements of the position?

Yes

Will you relocate if job required it?

Yes

Will you travel if job requires it?

Yes

Will you work overtime if required?

Yes

If you are under 18, can you furnish a work permit?

Yes

Have you been convicted of a felony in the past 7 years? (Such conviction may be relevant if job related, but does not bar you from employment)

Yes

Please explain

AN EQUAL OPPORTUNITY EMPLOYER

EMPLOYMENT HISTORY

List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in comment section below.

Employer

Telephone

Dates Employed

Address

Job Title

Hourly Rates Salary

Immediate Supervisor and Title

Reason for Leaving

May we contact for reference?

Yes

Later

Summarize the nature of the work performed and job responsibilities

Employer

Telephone

Dates Employed

Address

Job Title

Hourly Rates Salary

Immediate Supervisor and Title

Reason for Leaving

May we contact for reference?

Yes

Later

Summarize the nature of the work performed and job responsibilities

Employer

Telephone

Dates Employed

Address

Job Title

Hourly Rates Salary

Immediate Supervisor and Title

Reason for Leaving

May we contact for reference?

Yes

Later

Summarize the nature of the work performed and job responsibilities

Employer

Telephone

Dates Employed

Address

Job Title

Hourly Rates Salary

Immediate Supervisor and Title

Reason for Leaving

May we contact for reference?

Yes

Later

Summarize the nature of the work performed and job responsibilities

Comments (including explanation of any gaps in employment)

Skills and Qualifications - summarize any special trainings, skills, licenses, certificates and/or characteristics of yourself that may qualify you as being able to perform job-related functions for the position which you are applying

Educational Background (If job related)

List last three (3) schools attended, starting with most recent

School

Years Completed

Degree Diploma

GPA Class Rank

Major

Minor

List any foreign language(s) you know and check the boxes that describe your skill level

References

List names of persons not related to you who are willing to provide professionals and/or character references

Name

Phone

Years Known

List professional, trade, business, or civic association and any office held. (Exclude membership which would reveal sex, race, religion, national origin, age, color, disability, or other protected status)

Organization

Offices Held

List special accomplishment, publications, awards (Exclude membership which would reveal sex, race, religion, national origin, age, color, disability, or other protected status)

It is understood and agreed upon that any mispresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed.

I give the employer the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the employer and it's representatives for seeking such information and all other persons, corporations for furnishing such information.

The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 60 days. At the conclusion this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand it is this cpmpany's policy not to refuse to hire a qualified individual with a disability because of this person's need for an accommodation that would be required by the ADA

Applicant Full Name *

Date *

Referral Source
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Employee
Relative
Government Employment Agency
Walk-in
Private Employment Agency
Other

Name of Source (if applicable)

Interviewer's Comment