PERSONAL INFORMATION:

                    
Last Name                                  First Name                             M.I.

PRESENT ADDRESS:
              
 Street                                     City                                        State           Zip                          Phone

PERMANENT ADDRESS: (If different from present address)
              
 Street                                     City                                        State           Zip                          Phone

IF YOU CANNOT BE REACHED AT ABOVE PHONE NUMBER, WHERE MAY WE CONTACT YOU?


EMPLOYMENT DESIRED

Will you accept the following employment?

    FULL TIME? Y/N Yes No         PART TIME? Y/N Yes No          TEMPORARY? Y/N Yes No

Are you 18 years of age? Y/N Yes No                                      Are you employed now? Y/N Yes No

May we contact your current employer? Y/N Yes No

How did you learn of this opening? 

EDUCATION:

Select Highest Grade Level Completed:  Grade... 8 9 10 11 12 13 14 15 16 less than 8

Scholastic Honors Received: 

Extracurricular Activities While In School:

Number of Professional Organizations: Select 1 2 3 4 5

HONORS RECEIVED, VOLUNTEER OR COMMUNITY SERVICE OR OTHER QUALIFICATIONS POSSESSED YOU FEEL ARE RELATED TO THE POSITION FOR WHICH YOU ARE APPLYING?

Were you in the armed forces? Y/N Yes No   If so, what branch?  select Army Navy Airforce Marines

Dates of duty:  From: To:   Rank at Discharge:

PROFESSIONAL LICENSES AND/OR CERTIFICATIONS

     
Type                                    Organization / State Issued             Date Issued                         Number   

     
Type                                    Organization / State Issued             Date Issued                         Number   

     
Type                                    Organization / State Issued             Date Issued                         Number   

     
Type                                    Organization / State Issued             Date Issued                         Number   

IF YOUR FORMER EMPLOYMENT REFERENCES, EDUCATION OR MILITARY SERVICE ARE UNDER A NAME OTHER THAN INDICATED ON THIS APPLICATION, PLEASE INDICATE BELOW.

EMPLOYMENT RECORD

Former Employers information beginning with your present or most recent employer.

EMPLOYER 1:

Name                                     Address                                 City                                      State        Zip

Supervisor                            Phone                    Hire date             Last date             Start Wage           End Wage

Position & Duties

EMPLOYER 2:

Name                                     Address                                 City                                      State        Zip

Supervisor                            Phone                    Hire date             Last date             Start Wage           End Wage

Position & Duties

EMPLOYER 3:

Name                                     Address                                 City                                      State        Zip

Supervisor                            Phone                    Hire date             Last date             Start Wage           End Wage

Position & Duties

EMPLOYER 4:

Name                                     Address                                 City                                      State        Zip

Supervisor                            Phone                    Hire date             Last date             Start Wage           End Wage

Position & Duties

EMPLOYER 5:

Name                                     Address                                 City                                      State        Zip

Supervisor                            Phone                    Hire date             Last date             Start Wage           End Wage

Position & Duties

EMPLOYER 6:

Name                                     Address                                 City                                      State        Zip

Supervisor                            Phone                    Hire date             Last date             Start Wage           End Wage

Position & Duties

HAVE YOU EVER BEEN CONVICTED OF A CRIME?  Y/N Yes No

IF YES, WHAT, WHEN, AND WHERE?  
CONVICTION OF A CRIMINAL OFFENSE WILL NOT NECESSARILY PRECLUDE YOU EMPLOYMENT.

USE THIS SPACE TO GIVE US FURTHER INFORMATION WHICH WILL ASSIST US IN PLACING YOU, INCLUDING AT LEAST TWO PERSONAL REFERENCES NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEASE ONE YEAR.

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

By clicking on the "Submit" button below I voluntarily give this institution the right to make thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination, and this institution at such times may require such future physical examinations as and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which related to the essential duties I would be required to perform.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on the application form.

If employed, I will be required to complete any employment verification form (i-9), and within three days show satisfactory evidence of identity and eligibility for employment.

AVAILABILITY RECORD

PLEASE INDICATE DAYS AND HOURS YOU ARE AVAILABLE FOR WORK (BE SPECIFIC)

PRIMARY POSITION DESIRED:    WILL YOU ACCEPT ANOTHER POSITION?  Y/N Yes No

IF SO WHAT: 

ARE YOU AVAILABLE FOR WORK:       WEEKENDS? Y/N Yes No
                                                                HOLIDAYS?  Y/N Yes No
                                                   ROTATING SHIFTS? Y/N Yes No

DO YOU LIMIT YOUR ANNUAL EARNINGS DUE TO SOCIAL SECURITY OR OTHER REASONS?  Y/N Yes No
IF YES, PLEASE STATE WHAT IS THE MAXIMUM AMOUNT YOU WISH TO EARN:

IF YOUR AVAILABILITY CHANGES, IT IS YOUR RESPONSIBILITY TO FILL IN AN "AVAILABILITY CARD" INDICATING THE CHANGES. SUCH CHANGES WILL BE EFFECTIVE, THEN, FOR ANY FUTURE EMPLOYMENT.

By pressing the "Submit" button below I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administrator of the institution.

FOR THIS TYPE OF EMPLOYMENT, STATE LAW REQUIRES A CRIMINAL RECORD CHECK AS A CONDITION OF EMPLOYMENT.