Application for Employment

We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or Federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization.

Applicant name: ________________________Date:____________________

Position (s) applied for or type of work desired:________________________

Address:________________________________________________________

Telephone #: __________________ Social Security #:__________________

Type of employment desired:        _____full-time  _____ part-time   ____ temporary
Date you will be available to start work: _____________

Are you able to meet the attendance requirements?       ___ Yes ___ No
Do you have any objection to working overtime if necessary? ___Yes ___ No
Can you travel if required by this position? ___ Yes ___ No
Have you ever been previously employed by our organization? ___ Yes ___ No
Can you submit proof of legal employment authorization and identity? ___Yes___No
If you are under 18, can you furnish a work permit if it is required? ___ Yes ___ No
Have you ever been convicted of a crime in me last 7 years? ___Yes ___ No
If yes, please explain (a conviction will not automatically bar employment): ___________________________________________________________________________

_________________________________________________________________________

Drivers license number (if driving is an essential job duty): ___________________

How were you referred to us?____________________________________________

Employment History

Please provide all employment information for your past four employers starting with the most recent.

Employer:   _________________________  Position held: __________________

Address: ________________________________  Telephone #:   _____________

Immediate supervisor and title: __________________________________________

Dates employed: from______    to ______       Salary:___________

Job summary:_____________________________________________

Reason for leaving: _________________________________________

Employer:   _________________________  Position held: __________________

Address: ________________________________  Telephone #:   _____________

Immediate supervisor and title: __________________________________________

Dates employed: from______    to ______       Salary:___________

Job summary:_____________________________________________

Reason for leaving: _________________________________________

Employer:   _________________________  Position held: __________________

Address: ________________________________  Telephone #:   _____________

Immediate supervisor and title: __________________________________________

Dates employed: from______    to ______       Salary:___________

Job summary:_____________________________________________

Reason for leaving: _________________________________________