Employment Application

( * fields are required fields )
RESUME
PERSONAL INFORMATION
* First Name: * Last Name, MI:
* Street Address: * City:
* State: * Zip code:
* Home Phone: Business Phone:
* E-mail Address:
* APPLICATION DATE * POSITION APPLIED FOR
EDUCATION
* Select highest grade completed:
* Select number of years of post-high school education:
Additional Credits:
POST-HIGH SCHOOL EDUCATION
1. Name and Location of Institution:
Degree(s) Received
Major or Specialty: Minor:
Dates Attended: Honors
2. Name and Location of Institution:
Degree(s) Received:
Major or Specialty: Minor:
Dates Attended: Honors:
3. Name and Location of Institution:
Degree(s) Received:
Major or Specialty: Minor:
Dates Attended: Honors:
WORK EXPERIENCE
Starting with the most recent, describe ALL paid, military and applicable voluntary experience.  Highlight your knowledge, skills and abilities which best demonstrate your qualifications for this position.  You may list significantly different jobs within the same organization as separate items.
* May we contact your present supervisor?
Position 1 (start with most recent):
* Job Title: * Duties:
* Employer: * Address:
* Phone:  Immediate Supervisor:
Title: * Reason for leaving:
Your name if different from present:
* Salary (start): * Salary (finish):
* Dates (mo/yr): * To(mo/yr):
* Full-time or Part-time: Hours/week:
Position 2:
Job Title: Duties:
Employer: Address:
Phone: Immediate Supervisor:
Title: Reason for leaving:
Your name if different from present:
Salary (start): Salary (finish):
Dates (mo/yr): To (mo/yr):
Full-time or Part-time: Hours/week:
Position 3:
Job Title: Duties:
Employer: Address:
Phone: Immediate Supervisor:
Title: Reason for leaving:
Your name if different from present:
Salary (start): Salary (finish):
Dates (mo/yr): To (mo/yr):
Full-time or Part-time: Hours/week:
Position 4:
Job Title: Duties:
Employer: Address:
Phone: Business Type:
Immediate Supervisor: Title:
Number/Titles of employees you supervised:
Equipment Used: Reason for leaving:
Your name if different from present:
Salary (start): Salary (finish):
Dates (mo/yr): To (mo/yr):
Full-time or Part-time: Hours/week:
ADDITIONAL INFORMATION
* For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States?
 
Under the Immigration Reform and Control Act of 1986, you will be required to fill out a certification verifying that you 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?
If yes, did you serve during the Vietnam Conflict (2/28/61-3/7/75)?
   
* Have you ever been convicted for any violation(s) of law? NOT including moving traffic violations.
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?
REFERENCES
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 need to know basis for good cause shone as determined by the agency head or designee.
* FIRST & LAST INITALS: