Please answer the questions below and press submit when you are finished. Thank you for your application.
Cell Phone Number:
Home Phone Number:
Work Phone Number:
Do you wish to work: Part Time Full Time
If part time, specify days/hours:
Date available for work:
Do you have a current valid driver's license? Yes
Do you have any commitments to another employer that might affect your employment with us?
Typing Speed (words per minute):
Office Equipment Skills:
Computer Software Skills:
Fluency Level: Spoken Written
Are you legally authorized to work in the United States? SEARP&DC participates in E-Verify Yes No
Are you 18 years of age or older? Yes No
Do you know of any reason why you cannot perform the essential functions of the job for which you are applying with or without reasonable accommodation? Yes No
Have you ever been convicted of a felony? Yes No
If Yes, explain the number of convictions, nature of offense(s), and date(s)
Have you previously applied for employment with our organization? Yes No If 'Yes' please give the date:
Have you previously been employed by this organization? Yes No If 'Yes' please give the date:
Do you have any relatives working for this organization?_ Yes No
If 'Yes' give relatives names and relationships:
Name of High School attended and Location?
In High School, what was your Highest Grade, Degree, Major, Certification or Type of Course:
Name of College attended and Location?
In College, what was your Highest Grade, Degree, Major, Certification or Type of Course:
Name of Graduate school attended and Location?
In Graduate school, what was your Highest Grade, Degree, Major, Certification, or Type of Course:
Name and Location of other education:
Other Education Degrees or Achievements:
List all courses, workshops, or conferences and attach copies of certificates:
List at least four persons who are not related to you by blood, marriage, or adoption; one must be a former employer.
Employment History: beginning with current or most recent employer.
Name and address of previous employer: Job Title: Start Date: End Date
May we contact this employee? Yes No Supervisor's Name
Employer's Phone Number
Reason for Leaving:
Second, most recent employers name and address: Job Title: Start Date: End Date:
May we contact this employee: Yes No
Employer's Phone Number:
Third, most recent employers name and address: Job Title Start Date: End Date:
Supervisor's Phone Number:
Fourth, most recent employer's name and address: Job Title: Start Date: End Date:
By my signature and initials placed below, I promise that the information provided in this employment application (and accompanying resume, if any) is true and complete, and I understand that any false information or significant omissions may disqualify me for further consideration for employment, and may be justification for my dismissal from employment, if discovered at a later date. I agree to immediately notify the company if I should be convicted of a felony, or any crime involving dishonesty or a breach of trust while my job application is pending, or during my period of employment, if hired.
I authorize the investigation of all statements contained in this application (and accompanying resume, if any). I also authorize the company to contact my present employer (unless otherwise noted in this application form), past employers, and listed references.
I authorize any person, school, or current employer (except as previously noted), past employer(s), and organizations named in this application form (and accompanying resume, if any) to provide the Agency with relevant information and opinions that may be useful to the company in making a hiring decision, and I release such persons and organizations from any legal liability in making such statements.
I understand that if my employment is terminated by the Agency for dishonesty, breach of trust, or any criminal acts the authorities may be notified and I may be criminally prosecuted. I also understand that, if hired, I may not hold other employment, nor engage in sales, investments or other activities that create a conflict of interest with my position with this Agency.
I understand that this application does not, by itself, create a contract of employment. I understand and agree that, if hired, my employment is for no definite period of time, and may, regardless of the date of payment of my wages or salary, be terminated at any time. I understand that no person is authorized to change any of the terms mentioned in this employment application form.
Please Types Signature:
Date of Signing:
Position Applied For:
How were you referred to our Agency? Newspaper Private Employment Agency Relative or Friend Employed by the Agency Other(Please Explain) Explain
Check One: Male Female
Check One: White Black or African American Hispanic or Latino American Indian/Alaskan Native Asian Hawaiian Two or More Races
Check Any that may apply: Vietnam Era Veteran Disabled Veteran Disabled Person