|
*
= Required
|
Date:*
|
|
PERSONAL INFORMATION
|
First Name:*
|
Middle Name:
|
Last Name:*
|
Social Security
Number:*
|
Primary Phone #:*
|
Secondary Phone/Cell:
|
Present Address:*
|
Present City:*
|
Present State:*
|
Present Zip:*
|
Current Email:*
|
In case of
emergency notify:*
|
Emergency Phone #:*
|
| Are you prevented from
lawfully becoming employed in this country because of
Visa or Immigration status?*
|
Are you 18 years or
older?*
|
| EMPLOYMENT
DESIRED |
Position:*
|
Date you can
start:*
|
Annual Salary Desired:*
|
Are you employed now?*
|
If so, may we inquire of
your present employer?*
|
Have you ever
applied to this organization before?*
|
Where?
When?
|
Have you ever
worked for this organization before?**
|
Where?
When?
|
| Reason for leaving:
|
| Name of last
supervisor:
|
Who referred you to this
organization?*
|
| EDUCATION |
| School Level |
Name & location of school |
# of years attended |
Graduated |
| Grammar* |
|
|
|
|
Subjects studied:
|
| High
School* |
|
|
|
| |
Subjects studied:
|
| College (if
applicable) |
|
|
|
| |
Subjects studied:
|
| Other (if
applicable) |
|
|
|
| |
Subjects studied:
|
| GENERAL
|
| Special Training:
|
| Special Skills:
|
| Subjects of Special Study
or Research Work:
|
FORMER EMPLOYERS
(List below the last three
employers, starting with the last one first) |
|
Present or Immediate Past |
Name:*
|
Address:*
|
| |
City:*
|
State:*
|
Zip:*
|
| |
Start Date:*
|
Departure Date:*
|
| |
Monthly Start
Salary:*
|
Monthly End Salary:*
|
| |
Job Title:*
|
|
|
May we contact your
supervisor:
|
|
| |
Supervisor Name:
|
Title:
|
| |
Supervisor Phone:
|
| |
Description of Work:
|
| |
Reason for leaving:
|
| |
|
|
Past Employer 2 |
Name:*
|
Address:*
|
| |
City:*
|
State:*
|
Zip:*
|
| |
Start Date:*
|
Departure Date:*
|
| |
Monthly Start
Salary:*
|
Monthly End Salary:*
|
| |
Job Title:*
|
|
| |
May we contact your
supervisor:
|
|
| |
Supervisor Name:
|
Title:
|
| |
Supervisor Phone:
|
| |
Description of Work:
|
| |
Reason for leaving:
|
| |
|
|
Past Employer 3 |
Name:*
|
Address:*
|
| |
City:*
|
State:*
|
Zip:*
|
| |
Start Date:*
|
Departure Date:*
|
| |
Monthly Start
Salary:*
|
Monthly End Salary:*
|
| |
Job Title:*
|
|
| |
May we contact your
supervisor:
|
|
| |
Supervisor Name:
|
Title:
|
| |
Supervisor Phone:
|
| |
Description of Work:
|
| |
Reason for leaving:
|
REFERENCES
(List below the names of three
people not related to you whom you have known at least
one year) |
|
Name* |
Address* |
Business* |
Years Acquainted* |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| SERVICE RECORD
|
| Branch of Service:
|
Discharge Date:
|
| |
Rank
Obtained:
|
| Presently in Reserves or
Branch:
|
Date obligation ends:
|
| SPECIAL
QUESTIONS |
|
DO NOT answer ANY of these questions in
this framed area unless the employer has checked the box
with an X preceding the question. Thereby
indicating that the information is required for a bona
fide occupational qualification or is dictated by
national security laws, or is needed for other legally
permissible reasons. |
|
XAre you a United
States citizen?*
|
|
XAre
you able to perform each of the primary duties and
responsibilities for the position with or without an
accommodation?*
|
|
If you can perform the primary duties and
responsibilities for the position with an accommodation,
explain how you would perform the tasks, and with what
accommodations: |
|
|
|
XWhat foreign
languages do you SPEAK fluently?
|
| XWhat
foreign languages do you READ?
|
| XWhat
foreign languages do you WRITE?
|
|
|
|
|
|
|
XHave you been
convicted of a felony or misdemeanor within the last 5
years?*
|
Describe:
|
| |
XI understand and
agree that I may be required to take one or more
physical examination(s). I agree to consent to take
such test(s) at such time as designated in the
Organization and to release the Organization, its
Directors, Officers, Agents or Employees from any claim
arising in connection with the use of such test(s).*
|
| Signature:
Date:
|
|
* You will not be denied
employment solely because of a conviction record, unless
the offense is related to the job for which you have
applied.
|
|
AUTHORIZATION |
| I CERTIFY THAT ALL THE
INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE
AND COMPLETE, AND I UNDERSTAND THAT IF ANY FALSE
INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE
DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I AM
EMPLOYED, MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME.
IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO
THE ORGANIZATION'S RULES AND REGULATIONS, AND I AGREE
THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED,
WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT
ANY TIME, AT EITHER MY OR THE ORGANIZATION'S OPTION. I
ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS
OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE
AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE
ORGANIZATION. I UNDERSTAND THAT NO ORGANIZATION
REPRESENTATIVE OTHER THAN ITS PRESIDENT, AND THEN ONLY
WHEN IN WRITING AND SIGNED BY THE PRESIDENT, HAS ANY
AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR
ANY SPECIFIC PERIOD OF TIME, OR TO MAKE ANY AGREEMENT
CONTRARY TO THE FOREGOING. |
| |
|
|
Revision 06-05 |