Employment

Application for Employment

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    Personal Information

    Name:

    Mailing Address:

    Email:

    Employment Desired
    Position(s) applied for:
    Will you accept employment of:
    Are you 18 years of age or older:
    Education
    Highest grade completed:

    Grade School

    Completed
    Completed
    Completed
    Completed
    Completed
    Professional Licenses and/or Certifications

    License and/or Certification #1

    License and/or Certification #2

    License and/or Certification #3

    Upload License and /or Certifications

    Employment Record (list last or present position first)

    Employer 1

    Employer (company name)
    Immediate supervisor name
    Job title
    Street address
    Employment date (mo. & yr.)
    Salary
    City, State, Zip
    Phone
    Reason for leaving
    Summarize your job duties
    Is there any reason why you would not want us to contact this employer?

    Employer 2

    Employer (company name)
    Immediate supervisor name
    Job title
    Street address
    Employment date (mo. & yr.)
    Salary
    City, State, Zip
    Phone
    Reason for leaving
    Summarize your job duties
    Is there any reason why you would not want us to contact this employer?

    Employer 3

    Employer (company name)
    Immediate supervisor name
    Job title
    Street address
    Employment date (mo. & yr.)
    Salary
    City, State, Zip
    Phone
    Reason for leaving
    Summarize your job duties
    Is there any reason why you would not want us to contact this employer?
    Personal References (Do not include Relative or Former Employers)
    Name
    Phone#
    Business
    Years Acquainted
    Name
    Phone#
    Business
    Years Acquainted
    Name
    Phone#
    Business
    Years Acquainted
    TB Screening
    Are you willing to have a 2-step Mantoux administered or a chest x-ray for TB Screening? (paid for by Lange Board & Room)

    Background Study Information Request
    Gender
    Date of Birth
    Driver License or State ID #
    Upload License or State ID
    Race
    SSN
    Other Last Name
    Other First Name
    State Born In
    Have you lived in other states within last 5 years
    If yes, full address

    By my signature below, I promise that the information provided in this employment application ( and in any related documentation or interview) is true and complete, and I understand that any false or misleading information or significant omissions may disqualify me from further consideration from employment, and may lead to my dismissal from employment if discovered at a later date.

    Applicant’s Signature
    Date