Staff Use Only PIMA COUNTY LIBRARY EMPLOYMENT APPLICATION ...
[Pages:2]PIMA COUNTY LIBRARY EMPLOYMENT APPLICATION
ARIZONA@WORK Pima County One-Stop Career Centers
320 N Commerce Park Loop 2nd Floor, Tucson, AZ 85745 Phone: (520) 724-9649 Fax: (520) 770-4134
Staff Use Only Date Received______________ EST Class: ________________
Instructions: Please print clearly. Applicant must be 16 & older years of age. Please fill out completely, front and back, use black/blue ink only. (Must be completed by applicant and does not guarantee eligibility.)
(Resume is required for screening process and completion of Employment Skills Training Class)
Last Name, First Name, Middle Initial
,
Date of Birth
Age
Residence Street Address
Race/Ethnicity White/Caucasian African American City
Mailing Address
City
Social Security Number xxx - xx -
Home Phone Message Phone Email Address
Cell Phone Contact Name:
Hispanic
Native American or Native Alaskan
Asian/Pacific Islander
Other______________
How did you hear about the One Stop Career Center?
Zip Code Nearest Major Intersection to home
Gender Male Female
Zip Code
Are you currently enrolled in WIOA? Unsure Case Manager's Name
Yes No
# OF PEOPLE IN HOUSEHOLD:
Household income: Under $20,790 $20,791 to $25,665 $25,666 to $30,285 $30,286 to $35,882 Over $35,883
Does your household receive: TANF Food Stamps General Assistance Are you: Foster Child
Youth-on-your-own
Homeless Live in Group Home
Education Status (Check all that apply)
College Grad from
High School/GED Student
College Student
High School/GED Graduate
HS Dropout/Not Enrolled in School
School Presently Attending
Enrolled in Special Education? Yes No IEP? Yes No
Do you have any current certifications, licenses, etc? If so, Describe
Current Grade
9th
10th
11th 12th 12 + not in school
Do you have a r?sum??
Yes No If not in school, are you interested in going back?
Yes No
Have you ever completed Employment Skills Training Class?
If so, when?
Yes No
Where?_
Are You Bilingual? Yes Besides English, What language do you speak,
No read and/or
write?
Do you have a valid AZ driver's license? Yes No
What transportation do you have to and from work? (check all that apply)
bus
bike own car
friend/family none other
Have you ever been convicted of a felony? Yes No
Which library are you interested in interviewing for? _______________________________________________________________________________________
Over
Clerical Skills: (Check all that apply) Multi-Line Phones
Fax
Filing
Copying
Sort Mail
Typing/Data Entry---
10-Key
Customer Service
Cashier/Money-handling
Schedule Appointments/Meetings
Words Per Minute_________________
Computer Skills: Please specify: _______________________________________________________________________________________________________
Other Job Skills AND INTERESTS: Please list any other job skills and interests you have.
When are you available to work? Check all that apply.
Weekdays Weeknights Weekend days Weekend nights Part time Other:___________________________________
Employment History (Include Volunteer Jobs) :
Employer:
Address:
Job Title:
Dates of Employment (month/year) From:
To:
Employer:
Address:
Job Title:
Dates of Employment (month/year) From:
To:
Tasks Performed: (Please be specific)
Tasks Performed: (Please be specific)
I hereby certify that the information herein is true, and correct to the best of my knowledge. I am aware that should investigation at any time disclose any such misrepresentation or falsification, my application will be rejected and I may be dismissed from Arizona @ Work Programs. I agree to work cooperatively with staff and to provide pertinent employment information upon hire and/or discharge. By submitting this application, I certify that I am drug-free and eligible to work in the US.
Name:
Date:
................
................
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