QUESTIONS
If you are under 18 and it is required, can you furnish a work permit?
Yes
No
If No, please explain
Have you ever been employed here before?
Yes
No
If yes, please give dates & positions
Are you legally eligible for employment in this country?
Yes
No
* Date Available for Work
Desired salary range or rate of pay
Type of employment desired
(select)
Full-Time
Part-Time
Temporary
Seasonal
Co-Op
Answering "yes" to either of the following questions does not constitute an automatic bar to employment.
Have you ever pled guilty or no contest to, or ever been convicted of, a crime?
Yes
No
If yes, please provide date(s) of conviction(s), penalty(ies) imposed, and type(s) of
Have you ever been a defendant in a civil action for an intentional tort?
(e.g., a civil charge for assault, battery, intentional infliction of emotional distress,
false imprisonment, wrongful death, etc?
Yes
No
If yes, please provide the nature of the tort and disposition (how it was
EMPLOYMENT HISTORY
Starting with your most recent employer, please provide the following information:
Employer 1
Employer
Dates Employed (from)
Dates Employed (to)
How were you paid at the start?
(select)
Hourly
Salary
$
Commission, bonuses & other compensation
Address
City
State
Zip Code
Starting Job Title
Ending Job Title
Immediate Supervisor's Name
Immediate Supervisor's Title
May we contact supervisor for reference?
Yes
No
Why did you leave?
Type of work and responsibilities
What did you like most about job?
What did you like least about job?
Employer 2
Employer
Dates Employed (from)
Dates Employed (to)
How were you paid at the start?
(select)
Hourly
Salary
$
Commission, bonuses & other compensation
Address
City
State
Zip Code
Starting Job Title
Ending Job Title
Immediate Supervisor's Name
Immediate Supervisor's Title
May we contact supervisor for reference?
Yes
No
Why did you leave?
Type of work and responsibilities
What did you like most about job?
What did you like least about job?
Employer 3
Employer
Dates Employed (from)
Dates Employed (to)
How were you paid at the start?
(select)
Hourly
Salary
$
Commission, bonuses & other compensation
Address
City
State
Zip Code
Starting Job Title
Ending Job Title
Immediate Supervisor's Name
Immediate Supervisor's Title
May we contact supervisor for reference?
Yes
No
Why did you leave?
Type of work and responsibilities
What did you like most about job?
What did you like least about job?
EDUCATIONAL BACKGROUND
Starting with your most recent school attended, please provide the following information:
School 1
School Name
City
State
Years Completed
Education Completed
(select)
Diploma
GED
Degree
Certification
Other
If you selected Degree, Certification, or Other, please describe
GPA / Class Rank
Major / Minor
School 2
School Name
City
State
Years Completed
Education Completed
(select)
Diploma
GED
Degree
Certification
Other
If you selected Degree, Certification, or Other, please describe
GPA / Class Rank
Major / Minor
Protect the most important things around you
