Employment

Application for Employment

    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

    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

    Summarize your job duties
    Is there any reason why you would not want us to contact this employer?

    Employer 2

    Summarize your job duties
    Is there any reason why you would not want us to contact this employer?

    Employer 3

    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