Application For Employment Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department. Position(s) applied for: Referral Source: Advertisement Employee Relative Walk-in Other Name: (Last, First Middle) Address: City: State: Zip Code: Social Security # (123-45-6789) Telephone # Mobile/Beeper/Other Phone # E-mail Address: If necessary, best time to call you at home is: (AM/PM) May we contact you at work? Yes No If yes, work number: Best time to call at work is: (AM/PM) If you are under 18 and it is required, can you furnish a work permit? Yes No If no, please explain Have you submitted an application here before? Yes No If yes, give date(s) and position(s) Have you ever been employed here before? Yes No If yes, give dates 'From' and 'To': Are you legally eligible for employment in this country? Yes No Date available for work: What is your desired salary range? $ Per Type of employment desired: Full-Time Part-Time Temporary Seasonal Educational Co-op Are you able to meet the attendance requirements of the position? Yes No Will you work overtime if required? Yes No Have you ever been bonded? Yes No Have you ever pled "guilty" or "no contest" to, or been convicted of a crime? Yes No If yes, please provide date(s) and details: Answering, "yes" to these questions does not constitute an automatic bar to employment Factors such as date of the offense, seriousness and nature of the violation. Rehabilitation and position applied for will be taken into account Driver's license number if driving is an essential job function State Employment History Starting with your most recent employer, assignments or volunteer activities, provide the following information. Employer 1 Address Phone # Dates Employed: From: to: Compensation: (Starting) $ per Immediate Supervisor and Title Compensation: (Final) $ per Reason for leaving: May we contact for reference? Yes No Later Summarize the type of work performed and responsibilities: Employer 2 Address Phone # Dates Employed: From: to: Compensation: (Starting) $ per Immediate Supervisor and Title Compensation: (Final) $ per Reason for leaving: May we contact for reference? Yes No Later Summarize the type of work performed and responsibilities: Employer 3 Address Phone # Dates Employed: From: to: Compensation: (Starting) $ per Immediate Supervisor and Title Compensation: (Final) $ per Reason for leaving: May we contact for reference? Yes No Later Summarize the type of work performed and responsibilities: