Employment Application Employment Application Employment Application Last Name First Name Middle Name Other names you have used to identify yourself (for reference purpose only) Mailing Address Street City State Zip Code Permanent Address (if different from above) Phone Number Other numbers where you may be contacted Best time to contact you at home May we contact you at work Yes No If yes, work number and best time to call How were you referred to our organization? Have you been employed here before Yes No If yes, give dates (from, to) Date available to start work Are you legally authorized to work in the United States Yes No Have you ever been convicted of, or entered a plea of guilty or no-contest to a felony? ** Yes No If yes, please explain **This information may be considered in hiring or job placement, but will not automatically disqualify you for employment. WORK PREFERENCE Position applying for or type of work you are interested in Salary Expected Employment interest is Full Time Temporary Part Time Summer Date available to start work EDUCATIONAL RECORD High School - Name and Location Course of Study Year Completed 1 2 3 4 Did you graduate Yes No Certificate/Degree Received Technical School - Name and Location Course of Study Year Completed 1 2 3 4 Did you graduate Yes No Certificate/Degree Received College - Name and Location Course of Study Year Completed 1 2 3 4 Did you graduate Yes No Certificate/Degree Received College (additional) Course of Study Year Completed 1 2 3 4 Did you graduate Yes No Certificate/Degree Received Honors received including scholastic and honorary organizations to which you were elected or appointed Extracurricular activities in which you actively participated. Please indicate any offices held. ** **Applicant need not disclose any activities which might reveal them as a member of a protected class. LICENSES AND/OR CERTIFICATIONS Current Number Occupation Status of License Expiration Date Type License Certificate Registration State Issued Date Supervisory Experience Other Training and Experience EMPLOYMENT HISTORY List most recent first Company Name Date Started Date Ended Starting Salary Job Title City State Ending or Current Salary Supervisor's Name Phone Number Reason for Leaving Brief Job Description May we contact this employer Yes, Immediately Yes, At a later date No, Do not contact Company Name Date Started Date Ended Starting Salary Job Title City State Ending or Current Salary Supervisor's Name Phone Number Reason for Leaving Brief Job Description May we contact this employer Yes, Immediately Yes, at a later date No, do not contact Company Name Date Started Date Ended Starting Salary Job Title City State Ending Salary Supervisor's Name Phone Number Reason for Leaving Brief Job Description May we contact this employer Yes, Immediately Yes, at a later date No, do not contact REFERENCES List at least 3 references who are not relatives or employers Name Relationship/Title Mailing Address Phone Number Name Relationship/Title Mailing Address Phone Number Name Relationship/Title Mailing Address Phone Number Name Relationship/Title Mailing Address Phone Number PLEASE CLICK HERE TO READ THE APPLICANT STATEMENT I certify that I have read, fully understand and accept all terms as stated in the APPLICANT STATEMENT in the link above. * Certified reCAPTCHA Submit If you are human, leave this field blank.
