Employment

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Online Employment Application

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Date

Position Applying For:

Name

First Middle Last

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

Home Phone

Cellular/Other Phone

Primary phone number for calls related to this job opening

Work

Home

Cellular/Other

Can you provide proof, if hired, that you are eligible to work in the United States?

Yes

Are you 18 of age or over?

Have you ever been convicted of a crime other than a minor traffic violation?

Yes

If answered yes to the above question, please explain

Convictions are not an absolute bar to employment but will be considered in relation to the job requirements.

Do you have a valid Driver's License

Yes

License State

License Number

How did you learn about this opening?

Veteran's Preference

Do you claim Veteran's Preference?

Yes- Must attach DD-214, Report of Separation, and a letter less than 1 year old from the US Dept. of Veteran Affairs indicating disability

Do you claim Disabled Veteran's Preference?

Yes - Must attach DD-214, Report of Separation, and a letter less than 1 year old from the US Dept. of Veteran Affairs indicating disability

Spouse of Disabled Veteran?

Yes - Must attach copy of marriage certificate, DD-214, and a letter less than 1 year old from the US Dept. of Veteran Affairs indicating disability

Spouse of Deceased Veteran?

Yes - Must attach copy of marriage certificate, DD-214, and veteran’s death certificate

Education/ Training

Did you graduate from high school or receive a GED Certificate?

Yes

School Name

(college, vocational, or other)

School Location

Number of Credits

Please indicate the number of credits per Qtr. and Sem.

Field

Please indicate a Major and or Minor

Did you graduate?

Yes

Dipoloma or degree earned

School Name

(college, vocational, or other)

School Location

Number of Credits

Please indicate the number of credits per Qtr. and Sem.

Field

Please indicate a Major and or Minor

Did you graduate?

Yes

Dipoloma or degree earned

School Name

(college, vocational, or other)

School Location

Number of Credits

Please indicate the number of credits per Qtr. and Sem.

Field

Please indicate a Major and or Minor

Did you graduate?

Yes

Dipoloma or degree earned

Other education/Training/Skills:

Computer skills (hardware & software):

Related volunteer experience:

License or Certification

1) License/Certification

State

Profession

License/Certification #

Expiration Date

2) License/Certification

State

Profession

License/Certification #

Expiration Date

Employment History

(Provide detail; do not use “see resume.”)  Start with your current or last job – include armed forces service and self-employment.  Any change of job title under the same employer should be considered a separate position.

May we contact your current employer for a reference?

Yes

Not Applicable

1) Most Recent Employer

Phone Number

Supervisor's Name

Type of Business

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Job Title

Average Hours Worked Per Week

Dates Employed (indicate months & years)

From: - To:

Hourly Wage

Duties:

Please list responsibilities

Reason for Leaving or Reason for Considering Leaving If Still Employed

2) Employer

Phone

Supervisor's Name

Type of Business

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Job Title

Average Hours Worked Per Week

Dates Employed (indicate months & years)

From: - To:

Hourly Wage

Duties:

Please list responsibilities

Reason for Leaving or Reason for Considering Leaving If Still Employed

3) Employer

Phone Number

Supervisor's Name

Type of Business

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Job Title

Average Hours Worked Per Week

Dates Employed (indicate months & years)

From: - To:

Hourly Wage

Duties:

Please list responsibilities

Reason for Leaving or Reason for Considering Leaving If Still Employed

References

Reference 1

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Years Known

Reference 2

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Years Known

Reference 3

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Years Known

Upload Resume/ Cover Letter/ Other Documents

Max. file size: 256 MB.

Disclaimer and Signature

Date

Signature*

I certify that all information contained in this application and any attachments is true and complete to the best of my knowledge. I understand that any willful misrepresentation, false statement, or omission by me in the application or interview process will be cause for rejection of my application or termination of my employment. I authorize investigation of all statements made on this application and any attachments, and I release all persons, companies, and organizations from liability for providing or receiving such information. I further understand that this employment application and other employment related documents are not contracts of employment; and,that any oral or written statements to the contrary are hereby expressly disavowed.