Desired Position:

Date:

First Name:

Middle Name:

Last Name:

Street address:

City:

State:

Zip Code:

Cell Phone Number:

Home Phone Number:

Work Phone Number:

Email Address:

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

No

Preferred Salary:

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:

Other Skills:

Other Languages:

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

Job Duties:

Reason for Leaving:

Second, most recent employers name and address:

Job Title:

Start Date:

End Date:

May we contact this employee:
Yes
No

Supervisor's Name:

Employer's Phone Number:

Job Duties:

Reason for Leaving:

Third, most recent employers name and address:

Job Title

Start Date:

End Date:

May we contact this employee:
Yes
No

Supervisor's Name:

Supervisor's Phone Number:

Job Duties:

Reason for Leaving:

Fourth, most recent employer's name and address:

Job Title:

Start Date:

End Date:

May we contact this employee:
Yes
No

Supervisor's Name:

Supervisor's Phone Number:

Job Duties

Reason for Leaving:

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.

Initals

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.

Initals

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.

Initals

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.

Initals

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.

Initals

Please Types Signature:

Date of Signing:

Date:

Position Applied For:

Do you have a CDL?
Yes
No

Class of drivers liscense:
Class A
Class B
Class C

Endorsements:

Liscense Number:

State:

Have you had any traffic violations or convictions in the past 5 years?
Yes
No
An affirmative answer will not automatically disqualify you from beling considered as a candidate for employment.

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

Add Resume: