Employment History continued

Employer:   _________________________  Position held: ______________

Address: ________________________________  Telephone #:__________

Immediate supervisor and title:____________________________________

Dates employed: from______    to ______       Salary:___________

Job summary:_____________________________________________

Reason for leaving: _________________________________________

Other Skills and Qualifications

Summarize any job-related training, skills, licenses, certificates, and/or other qualifications:_____________________________________________

__________________________________________________________________________

__________________________________________________________________________

Educational History

List school name and location, years completed, course of study, and any degrees earned: High school:____________________________

College:  _____________________________________

Technical Training: ___________________________________________

Other: _____________________________________________________

References

List 3 references names, telephone numbers, and years known (do not include relatives or employers):

_________________________________________________________________

___________________________________________________________________

_____________________________________________________________________

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of (his application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either 1 or the employer can terminate (the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because that persons need for a reasonable accommodation as required by the AIM.

I also understand that if I am employed. I will be required (to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Applicant signature:___________________________ Date: ____________