|
Position applied for
|
|
|
|
Date of Application
|
|
|
|
Applicant name: Last, First, Middle
|
|
|
|
Address, City, State and Zip
|
|
|
|
Telephone (including area code)
|
|
|
|
Cell phone/Beeper/Other
|
|
|
|
Email address
|
|
|
|
Referral source (how did you hear about us?)
|
|
|
|
If under 18 can you furnish a work permit if required?
|
no
yes
|
|
If no, please explain
|
|
|
|
Have you ever been employed here before?
|
no
yes
|
|
If yes, give dates and positions
|
|
|
|
What is your desired salary range?
|
|
|
|
Are you legally eligible for employment in this country?
|
no
yes
|
|
Type of employment desired
|
Educational Co-op
Full-Time
Part-Time
Seasonal
Temporary
|
|
Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accomodation)? This question is not designed to elicit information about an applicant's disablility. Please do not provide information about the existence of a disability, particular accomodation, or whether accomodation is necessary. These issues will be addressed at a later stage to the extent permitted by law.
|
no
yes
|
|
Do you need additional information about the job's essential functions to respond ?
|
no
yes
|
|
Have you ever pled guilty or no contest to or been convicted of a crime?
|
no
yes
|
|
If yes, provide dates and details
|
|
|
|
Do you have an outstanding student loan?
|
no
yes
|
|
1. Previous employer Name and Address (beginning with most recent)
|
|
|
|
To and from dates employed
|
|
|
|
Position held
|
|
|
|
Type of work performed and responsibilites
|
|
|
|
Salary/year or amount/hour
|
|
|
|
Immediate supervisor
|
|
|
|
May we contact for reference ?
|
no
yes
|
|
Why did you leave ?
|
|
|
|
2. Next previous Employer name & address
|
|
|
|
To and from dates employed
|
|
|
|
Position held
|
|
|
|
Type of work performed and responsibilites
|
|
|
|
Salary/year or amount/hour
|
|
|
|
Immediate supervisor
|
|
|
|
May we contact for reference ?
|
no
yes
|
|
Why did you leave ?
|
|
|
|
3. Next previous Employer name & address
|
|
|
|
To and from dates employed
|
|
|
|
Position held
|
|
|
|
Type of work performed and responsibilities
|
|
|
|
Salary/year or amount/hour
|
|
|
|
Immediate supervisor
|
|
|
|
May we contact for reference?
|
no
yes
|
|
Why did you leave?
|
|
|
|
Training , skills, licenses & certificates
|
|
|
|
Education- School attended (beginning with the most recent)
|
|
|
|
Years attended
|
|
|
|
Completed
|
Certification
Degree
Diploma
GED
|
|
2.Next most recent school attended
|
|
|
|
Years attended
|
|
|
|
Completed
|
Certification
Degree
Diploma
GED
Other
|
|
3.Next most recent school attended
|
|
|
|
Years attended
|
|
|
|
Completed
|
Certification
Degree
Diploma
GED
Other
|
|
Computer skills (word processing,spreadsheets, email, internet, other)
|
|
|
|
1. Reference (not related to you)
|
|
|
|
Title
|
|
|
|
Telephone
|
|
|
|
Number of years known
|
|
|
|
2. Reference (not related to you)
|
|
|
|
Title
|
|
|
|
Telephone
|
|
|
|
Number of years known
|
|
|
|
3. Reference (not related to you)
|
|
|
|
Title
|
|
|
|
Telephone
|
|
|
|
Number of years known
|
|
|
|
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 employers service, whenever it is discovered.
|
|
|
|
I fully understand and agree
|
|
|
Date of agreement
|
|
|
Home
