High Desert Leapin’ Lizards, Inc
High Desert Leapin’ Lizards, Inc.
348 Rowe Rm 12 APPLICATION FOR EMPLOYMENT
Ridgecrest, CA 93555
|DATE |
|PROGRAM/SITE |
| PERSONAL | |
|NAME (LAST FIRST |TELEPHONE |
|MIDDLE) | |
| |( ) |
|ADDRESS |ARE YOU 18 YEARS OF AGE OR OLDER? |
| |__ YES __ NO IF NO, PLEASE STATE AGE |
| |____________________ |
|SOCIAL SECURITY NUMBER: (VOLUNTARY) |DATE OF LAST PHYSICAL EXAM |DATE OF LAST TB |
| | | |
|- | | |
|HAVE YOU EVER BEEN EMPLOYED UNDER A DIFFERENT NAME? __ YES __ NO IF YES, PLEASE LIST ALL NAMES USED |
| |
|DO YOU POSSESS A VALID CA DRIVER’S LICENSE? __ YES __ NO |HAS YOUR DRIVER’S LICENSE EVER BEEN SUSPENDED OR REVOKED? |
| | |
|CDL NUMBER |__ YES __ NO IF YES, PLEASE EXPLAIN ON BACK OF FORM |
|NEAREST LIVING RELATIVE- NAME: |TELEPHONE NUMBER |RELATIONSHIP |
| | | |
|ADDRESS |
| |
|POSITION APPLYING FOR |
|TITLE |SALARY REQUESTED |HOURS REQUESTED |DATE AVAILABLE |
| | | | |
|PREVIOUS EMPLOYMENT (LIST MOST RECENT EXPERIENCE FIRST) |
|NAME & ADDRESS OF EMPLOYER |TELEPHONE NUMBER |JOB TITLE AND |REASON FOR |DATE FROM |DATE |
| | |TYPE OF WORK |LEAVING | |TO |
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| EDUCATION |
|CIRCLE HIGHEST YEAR COMPLETED |DIPLOMA |CURRENTLY ENROLLED IN HIGH SCHOOL COMPLETION COURSE? |
| | | |
|6 7 8 9 10 11 12 | |__ YES __ NO IF YES, GIVE EXPECTED COMPLETION DATE |
|EDUCATION CONTINUED |
|NAME OF UNIVERSITY, COLLEGE OR BUSINESS SCHOOL |MAJOR |# OF |# OF |DIPLOMA |DATE |
|AND ADDRESS |SUBJECT |YEARS |UNITS |DEGREE OR |COMPLETED |
| | |COMPLETED |COMPLETED |CERTIFICATE | |
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|PROFESSIONAL REFERENCES |
|LIST THREE PERSONS THAT CAN GIVE INFORMATION ABOUT YOUR BACKGROUND, CHARACTER, ABILITITIES, ETC. |
|NAME |ADDRESS |TELEPHONE |RELATIONSHIP TO YOU |
| | |NUMBER |(FRIEND, EMPLOYER, ETC) |
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|PROFESSIONAL AND TECHNICAL QUALIFICATIONS |
| LIST LICENSES OR CERTIFICATES OF COMPETENCIES HELD: |
| |
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|NAMES OF PROFESSIONAL ASSOCIATIONS OF WHICH YOU ARE A MEMBER: |
| |
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|Criminal Record Statement |
|Have you ever been convicted of a crime in any state, federal court, military or jurisdiction outside of the US? __ Yes __ No |
|If the criminal background check reveals any conviction(s) that you did not disclose on this form, your failure to disclose the conviction(s) |
|may result in immediate termination. If you answered yes, give details indicating the nature and circumstances of the crime and the date and |
|location in which each crime occurred. |
|NOTES: |
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|__________________________________________________________________________________________________________________ |
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|__________________________________________________________________________________________________________________ |
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|__________________________________________________________________________________________________________________ |
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|__________________________________________________________________________________________________________________ |
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|__________________________________________________________________________________________________________________ |
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|__________________________________________________________________________________________________________________ |
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|__________________________________________________________________________________________________________________ |
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|__________________________________________________________________________________________________________________ |
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|I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT. I GIVE MY PERMISSION FOR ANY NECESSARY |
|VERIFICATION. |
|SIGNATURE OF APPLICANT |DATE |
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