Employment Application

Please complete all questions for employment consideration

 

Name:                                                                          Social Security Number:                                            

 

Present Address:                                                                                                                                            

                                    Street                                                   City                             State                Zip

 

Home Phone:                                                              How did you hear of us?                                           

 

If employee referral, please provide their name:                                                                                            

 

Type of work or position applied for:                                                             ¨ Full Time   ¨ Part Time

 

                                                                                                                        Date Available to

Days Available                                    Hours Available                                  Begin Work                            

 

Describe why you are qualified for the position:                                                                                           

                                                                                                                                                                       

(Attach resume if possible)

 

Salary requirements:                                                                Are you over 18:         ¨  Yes            ¨  No

                                                                                                                                                                       

 

Have you been employed by us before?   ¨  Yes      ¨  No  If yes, when?                                                 

 

Have you applied for                                                              Date and

employment with us previously?  ¨  Yes       ¨  No              Result:                                                            

 

If you have relatives employed with us, their name/relationship:                                                                  

                                                                                                                                                                       

 

If you would be engaged in any other work while in our employ, please explain:                                       

                                                                                                                                                                       

                                                                                                                                                                       

 

If hired, can you demonstrate eligibility to work in the United States?                                ¨  Yes   ¨  No

 

Have you ever been convicted, pleaded guilty, or pleaded "no contest" to any crime?         ¨  Yes   ¨  No

If yes, please explain:                                                                                                                                     

 

Has a former employer ever disciplined you for tardiness or absenteeism?                           ¨  Yes   ¨  No

If yes, please explain:                                                                                                                                     

 

Would a former employer categorize your attendance as meeting expectations?                  ¨  Yes   ¨  No

If no, please explain:                                                                                                                                      

 

After hearing of the job duties, to the best of your knowledge would you be able to perform all the

essential functions of this position?                ¨  Yes   ¨  No

                                                                                                                                                                       


HISTORY OF EMPLOYMENT

List your complete employment record (including temporary, regular and part-time) in date order.

List the most recent first.  Include military service if applicable.

                                                                                                                                                                       

MOST RECENT EMPLOYER

Company Name:                                                                                  Phone Number:                                   

 

Address:                                                                                                                                                         

 

Supervisor's Name/Title:                                                                                                                                 

 

Starting Position:                                                                      Ending Position:                                              

 

From:                           To:                               Beginning Salary:                     Ending Salary:                        

 

Brief Job Description:                                                                                                                                     

 

Reason for Leaving:                                                                                                                                       

Are you currently working for this company?    ¨  Yes  ¨  No    If yes, may we contact? ¨  Yes   ¨  No

                                                                                                                                                                       

EMPLOYER

Company Name:                                                                                  Phone Number:                                   

 

Address:                                                                                                                                                         

 

Supervisor's Name/Title:                                                                                                                                 

 

Starting Position:                                                                      Ending Position:                                              

 

From:                           To:                               Beginning Salary:                     Ending Salary:                        

 

Brief Job Description:                                                                                                                                     

 

Reason for Leaving:                                                                                                                                       

Are you currently working for this company?    ¨  Yes  ¨  No    If yes, may we contact? ¨  Yes   ¨  No

                                                                                                                                                                       

EMPLOYER

Company Name:                                                                                  Phone Number:                                   

 

Address:                                                                                                                                                         

 

Supervisor's Name/Title:                                                                                                                                 

 

Starting Position:                                                                      Ending Position:                                              

 

From:                           To:                               Beginning Salary:                     Ending Salary:                        

 

Brief Job Description:                                                                                                                                     

 

Reason for Leaving:                                                                                                                                       

Are you currently working for this company?    ¨  Yes  ¨  No    If yes, may we contact? ¨  Yes   ¨  No

                                                                                                                                                                       

If you were employed under a different name in any of those positions, give name and applicable company:

                                                                                                                                                                       

                                                                                                                                                                       


 

Account for periods of 2 weeks or more in which you have not been working in the last 5 years:

 

From:                           To:                               Reason:                                                                                               

 

From:                           To:                               Reason:                                                                                               

 

work References

Please list three professional (work) references.

Full Name

 

Title

 

Company

 

Phone

(           )

Address

 

Full Name

 

Title

 

Company

 

Phone

(           )

Address

 

Full Name

 

Title

 

Company

 

Phone

(           )

Address

 

 

EDUCATIONAL BACKGROUND

 

School Name/

Address

Dates

Attended

Date

Graduated

Diploma/Degree

Certificate

Grade Point/

Honors

HIGH SCHOOL

 

 

 

N / A

 

 

 

BUSINESS / TRADE

 

 

 

 

 

 

 

COLLEGE/UNIV.

 

 

 

 

 

 

 

 

INDICATE TRAINING OR EXPERIENCE IN THE FOLLOWING:

 

10 Key:                                                Sight    ¨         Touch  ¨

 

Computer Skills:                      Word   ¨         Excel   ¨         Windows  ¨  Version:                        

                                                Power Point  ¨     Publisher  ¨

 

Other Equipment:                                                                                                                                           

 

Other Skills / Qualifications:                                                                                                                           

                                                                                                                                                                       

 

ACKNOWLEDGEMENT OF UNDERSTANDING AND CONSENT

Please read thoroughly before signing

 

It is understood that this application is not an obligation of employment.

 

I hereby authorize the Bond County Health Department (BCHD) to investigate all references and former employment, and I release from liability those supplying such information.  Upon offer of employment, I may be required to take a drug test at BCHD's expense and realize that the offer of employment is contingent upon my test results being drug-free and appropriate information being received from reference sources.

 

I will provide proof of my eligibility to work within 3 business days as required by "The Immigration Reform and Control Act of 1986".

 

I understand that BCHD can make no guarantee as to the number of hours that I may be assigned from week to week, and any reduction in hours can affect my compensation and benefits.  I also understand that I may be required to change days off and scheduled hours on a temporary or regular basis in order to continue my employment.  Also, I understand that the company reserves the right to transfer me to another position, as business necessitates, and my continue employment may be predicated upon my acceptance of said transfer.  I understand that evenings or weekends may be part of any schedule I may be assigned.

 

I understand that my employment is not governed by any written or oral contract and is considered an "at will" arrangement.  I understand that I am free, as is BCHD, to terminate employment at any time for any reason, so long as there is no violation of applicable Federal or State law.

 

I state that the information on this application is true and complete.  False statements, misrepresentations, or omission may be cause for cancellation of an employment offer or termination, even if already employed.  I agree that I have read and understand the above acknowledgements and agreements and recognize all of the above as conditions of employment.

 

 

                                                                                                                                                                       

Signature                                                                                                        Date

 

                                                                                                                                                                       

 

DO NOT WRITE BELOW THIS LINE - FOR EMPLOYER USE

 

INTERVIWED BY:                                                                                         DATE:                                    

REMARKS:                                                                                                                                                    

                                                                                                                                                                       

NEATNESS:                                                    ABILITY:                                                                               

HIRED:  □  Yes             □  No                         POSITION:                                                                             

DEPT.:                                                             DATE REPORTING TO WORK:                                            

SALARY/WAGE:                                FULL-TIME:                                        PART-TIME:                          

APPROVED:  1.                                              2.                                             3.                                            

                                    Administrator                           Dept. Supervisor                      General Manager

 

AN EQUAL OPPORTUNITY EMPLOYER