*
*
* First Name:
* Last Name, MI:
Social Security No:
(Note: Failure to submit social security number on this form will not prohibit employment consideration. Social seurity number may be required on other forms prior to employment.)
* Street Address:* City:
* State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Zip code:
* Home Phone:Business Phone:
* E-mail Address:
* Select highest grade completed:
Select one
12
11
10
9
8
7
6
5
4
3
2
1
If you did not complete high school, do you have a high school equivalency diploma?
Select one
Yes
No
* Select number of years of post-high school education:
Select one
7
6
5
4
3
2
1
None
1. Name and Location of Institution:
Honors: Degree(s) Received
Major or Specialty:
Minor:
Dates Attended:
2. Name and Location of Institution:
Honors:
Degree(s) Received:
Major or Specialty:
Minor:
Dates Attended:
3. Name and Location of Institution:
Honors:
Degree(s) Received:
Major or Specialty:
Minor:
Dates Attended:
Starting with the most recent, describe ALL paid, military and applicable voluntary experience. Hightlight your knowledge, skills and abilities which best demonstrate your qualifications for this position. You may list significantly different jobs within the same organization as seperate items.
* May we contact your present supervisor?
Select one
Yes
No
Postion 1 (start with most recent) :
* Job Title:* Duties:
* Employer:* Address:
* Phone: Business Type:
Immediate Supervisor:
Title:
Number/Titles of employees you supervised:
Equipment Used:
* Reason for leaving:
* Salary (start):* Salary (finish):
* Dates (mo/yr):* To(mo/yr):
* Full-time or Part-time:
Select one
Full-time
Part-time
Hours/week:
Postion 2:
Job Title:
Duties:
Employer:
Address:
Phone:
Business Type:
Immediate Supervisor:
Title:
Number/Titles of employees you supervised:
Equipment Used:
Reason for leaving:
Salary (start):
Salary (finish):
Dates (mo/yr):
To(mo/yr):
Full-time or Part-time:
Select one
Full-time
Part-time
Hours/week:
Postion 3:
Job Title:
Duties:
Employer:
Address:
Phone:
Business Type:
Immediate Supervisor:
Title:
Number/Titles of employees you supervised:
Equipment Used:
Reason for leaving:
Salary (start):
Salary (finish):
Dates (mo/yr):
To(mo/yr):
Full-time or Part-time:
Select one
Full-time
Part-time
Hours/week:
Postion 4:
Job Title:
Duties:
Employer:
Address:
Phone:
Business Type:
Immediate Supervisor:
Title:
Number/Titles of employees you supervised:
Equipment Used:
Reason for leaving:
Salary (start):
Salary (finish):
Dates (mo/yr):
To(mo/yr):
Full-time or Part-time:
Select one
Full-time
Part-time
Hours/week:
* For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States?
Select one
Yes
No
Under the Immigration Reform and Control Act of 1986, you will be required to fill out a certification verifying that yu are eligible to be employed and verifying your identity. Further, you will be required to provide documentation to that effect should you be employed.
* Are you a veteran who received an honorable discharge and has provided more than 180 consecutive days of full-time active-duty in the armed forces of the United States or reserve components thereof, including the National Guard, or has a service-connected disability rating fixed by the United States Veterans Affairs?
Select one
Yes
No
If yes, did you serve during the Vietnam Conflict (2/28/61-3/7/75)?
Select one
Yes
No
* Have you ever been convicted for any violation(s) of law, including moving traffic violations.
Select one
Yes
No
If YES, please provide the following:
Description of offense:
Statute of ordinance (if known):
Date of Charge:
Date of Conviction:
County, City, State of Conviction:
Additional Convictions:
* When will you be able to start work? (No date is neccessary if you are available as soon as you give two (2) weeks notice.)
Please provide us with 3 professional references:
Reference 1:
Name/Title
Phone number:
Reference 2:
Name/Title
Phone number:
Reference 3:
Name/Title
Phone number:
I herby certify that all entries on this application are true and complete, and I agree and understand that any falsifications of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment with SSI. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent that you may contact references, former employers and educational institutions listed regarding this application. I further authorize SSI to rely upon and use as it sees fit, any information received from such contacts. Information maintained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a kneed to know basis for good cause shone as determined by the agency head or designee.
FIRST & LAST INITALS:
