EMPLOYMENT APPLICATION
EMPLOYMENT APPLICATION
Applications are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or in the presence of a non-related medical condition or handicap.
Name_______________________________________________________Date___________________
Address___________________________________________________Phone #___________________
City_____________________State_____Zip__________Social Security #_______________________
DOB_________________ Are you a citizen of the United States of America? [ ] Yes [ ] No
Have you applied here before? [ ] Yes [ ] No When?______Position applied for?_________________
Start When_______________ [ ] Full time [ ] Part time [ ] Temporary [ ] Other__________________
EMPLOYMENT EXPERIENCE; Start with your present job or last job. Include military assignments and other volunteer activities. Exclude organizational names which indicate race, color, religion, sex, or national origin
Employer 1__________________________________________________________________________
Address___________________________________City________________State_____Zip__________
Phone #________________Supervisors’ Name_____________________________________________
Job Title______________________Reason for leaving_______________________________________
Dates of Employment: From_________To__________Salary or Hourly rate______________________
Employer 2__________________________________________________________________________
Address___________________________________City________________State_____Zip__________
Phone #________________Supervisors’ Name_____________________________________________
Job Title______________________Reason for leaving_______________________________________
Dates of Employment: From_________To__________Salary or Hourly rate_____________________
Employer 3__________________________________________________________________________
Address___________________________________City________________State_____Zip__________
Phone #________________Supervisors’ Name_____________________________________________
Job Title______________________Reason for leaving_______________________________________
Dates of Employment: From_________To__________Salary or Hourly rate______________________
EMPLOYMENT APPLICATION PART 2
EDUCATION
Schools/Colleges Attended: # Years Year Grad. Degree
____________________________________________________ _______ _______ ___________
____________________________________________________ _______ _______ ___________
____________________________________________________ _______ _______ ___________
Describe any special qualifications for this job:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Drivers License #_______________________________State__________Expiration_______________
Are you CPR Certified (current)? [ ] Yes [ ] No
Are you First Aide Certified (current)? [ ] Yes [ ] No
Have you had a TB Test in the past 2 years? [ ] Yes [ ] No
Have you ever been charged with a misdemeanor or felony? [ ] Yes [ ] No
If yes, what and when? _________________________________________________________
___________________________________________________________________________________
Are you a veteran of the U.S. Military service? [ ] Yes [ ] No
I CERTIFY that answers given herein are true and complete to the best of my knowledge. I authorize investigations of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not intended to be a contract of employment. In the event of employment, I understand that false or misleading information given on my application or interview may result in termination.
Signature___________________________________________________Date_____________________
For Personnel Department only
OFFER OF EMPLOYMENT:
Position: ______________________________________
Wage: ________________________________________
Start Date: _____________________________________
Scheduled Hours: _______________________________
LICENSING:
Background Forms Sent: [ ] Yes [ ] No Date: ________________
CPR Certification Sent: [ ] Yes [ ] No Date: ________________
First Aide Certification Sent: [ ] Yes [ ] No Date: ________________
BACKGROUND:
ND Criminal Background Verified: [ ] Yes [ ] No
ND Findings: _________________________________________________________
_________________________________________________________
MN Criminal Background Verified: [ ] Yes [ ] No
MN Findings: _________________________________________________________
_________________________________________________________
REMARKS: ________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Accurate Credit Bureau fax 626 398-0642
I wish to order [ ] Credit Report [ ] DMV Records [ ] Reference Verification [ ]Criminal Records
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