Employment Application

EMPLOYMENT APPLICATION

Please note that this information is being gathered to help us provide You or Your Client with a service that will meet their needs. The information will be treated in STRICT CONFIDENCE. ALL POTENTIAL EMPLOYEES ARE EVALUATED WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, MARITAL OR VETERAN STATUS, THE PRESENCE OF A NON-JOB RELATED HANDICAP OR ANY OTHER LEGALLY PROTECTED STATUS. APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS.

PERSONAL INFORMATION

Name of Applicant(required)

Best Contact Information For Applicant(required)

Current Address of Applicant and How long at Address?(required)

Phone Number (required)

Your E-mail Address (required)

Your Website

Age, If you are under age 18, do you have an employment/age certificate?

Sex

Married, Family. List your dependents, include spouse/defacto/partner/children

Given Name of Applicant

Family Name of Applicant

Does Applicant Use or Has Used Other Names? Please give other name(s)

Were You Born Outside of the United States?

Are You a United States Citizen Legally Authorized to Work in the United States? If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States. (required)

POSITION SOUGHT

What Type of Position are You Applying for and Are You Applying For Full Time. Part Time, or Temporary Work?

What Shift(s) Will You Work? Days, Evenings, or Nights?

If applying for temporary work, when will you be available? If hired, on what date can you start working? Can you work on the weekends? Can you work evenings? Are you available to work overtime?

If hired, would you have transportation to/from work?

Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation? If no, describe the functions that cannot be performed. (Note: Some companies comply with the ADA standards and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)

May We Contact Present Employer?

EMPLOYMENT HISTORY

EMPLOYMENT HISTORY – Please list your work experience for the past ten (10) years beginning with your most recent job held. If you were self-employed, give firm name.

Provide Company #1 Name, City, State, Dates of Employment, Job Titles, Describe Duties, Reason for Leaving, Supervisor’s Name, Telephone Number, Salary, skills used or learned, advancements or promotions while you worked at this company.

Provide Company #2 Name, City, State, Dates of Employment, Job Titles, Describe Duties, Reason for Leaving, Supervisor’s Name, Telephone Number, Salary, skills used or learned, advancements or promotions while you worked at this company.

Provide Company #3 Name, City, State, Dates of Employment, Job Titles, Describe Duties, Reason for Leaving, Supervisor’s Name, Telephone Number, Salary, skills used or learned, advancements or promotions while you worked at this company.

Provide Company #4 Name, City, State, Dates of Employment, Job Titles, Describe Duties, Reason for Leaving, Supervisor’s Name, Telephone Number, Salary, skills used or learned, advancements or promotions while you worked at this company.

MILITARY – Branch of Service:
Give Specialty, Date Entered, Discharge Date and Describe any military training received relevant to the position for which you are applying:

EDUCATION AND TRAINING

EDUCATION/TRAINING – Attend High School/GED?
Have you obtained a high school diploma or GED certificate? Provide School Name, Location, Diploma/Degree, Years attended, Subject Of Specialization, Including Technical Courses, Academic Achievements.

EDUCATION/TRAINING – Attend High School/GED ?
Have you obtained a high school diploma or GED certificate? Provide School Name, Location, Diploma/Degree, Years attended, Subject Of Specialization, Including Technical Courses, Academic Achievements.

EDUCATION/TRAINING – Attend Junior College? Provide School Name, Location, Diploma/Degree, Years attended, Specialized Courses and Training, Including Technical Courses, Academic Achievements.

EDUCATION/TRAINING – Attend College/University? Provide School Name, Location, Diploma/Degree , Years attended, Specialized Courses and Training, Including Technical Courses, Academic Achievements.

EDUCATION/TRAINING – Attend College/University? Provide School Name, Location, Diploma/Degree, Years attended, Specialized Courses and Training, Including Technical Courses, Academic Achievements.

EDUCATION/TRAINING – Attend Post Graduate College/University? Provide School Name, Location, Diploma/Degree, Years attended, Specialized Courses and Training, Including Technical Courses, Academic Achievements.

EDUCATION/TRAINING – Attend Post Graduate College/University? Provide School Name, Location, Diploma/Degree, Years attended, Specialized Courses and Training, Including Technical Courses, Academic Achievements.

EDUCATION/TRAINING – Attend Professional School? Provide School Name, Location, Diploma/Degree, Years attended, Specialized Courses and Training, Including Technical Courses, Academic Achievements.

EDUCATION/TRAINING – Attend Business or Trade School? Provide School Name, Location, Diploma/Degree, Years attended, Specialized Courses and Training,Including Technical Courses, Academic Achievements.

CLERICAL SKILLS – To Be Completed for Clerical Positions.
Please Provide Your Typing-WPM, Shorthand-WPM, Medical Terminology ? Legal Terminology? Ten-Key Adding? Word Processing, Excel, Ad Layouts, Desktop Publishing, Multi-Media, etc. and List Specific Computer Skills –

List Any Professional Licenses

Do You have A Drivers License, if so, Give State, if Operator, Commercial, Chauffeur, Your Driving History including accidents and moving violations during the past three years, Expiration Date

OTHER SPECIAL SKILLS:
Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with a company? If yes, please List Other Specific Skills You Have to Offer for Any Job Opening and explain how.

Do you speak, write or understand any foreign languages? If yes, describe which languages(s) and how fluent of a speaker you consider yourself to be.

Do You Speak a Language Other than English at Home? If so, which one?

ADDITIONAL INFORMATION

HAVE YOU EVER BEEN CONVICTED OF A CRIME? If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. (Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Have you ever been involuntarily terminated or asked to resign from any position of employment? If yes, please describe circumstances:

Has You Ever Attempted to Inflict Serious Self Harm? If yes, please elaborate.

Do You Have Any Behavioural Problems? If yes, please elaborate.

Do You Receive Any Support / Assistance from Any Services for These Problems? If yes, please elaborate.

Are you aware of any serious physical health problem you may currently be suffering from or have suffered from in the past?If yes please elaborate.

Have You Ever Suffered from Any Psychiatric illness? If yes please elaborate.

Are You Living with Any Psychiatric illness at present? If yes, please elaborate.

Are You in Contact with Any Support Agency Concerned with Psychiatric illness or with Any Psychiatric Unit? If yes, please give details.

Are You on Any Type of Medication? If yes, please give details.

Do You Have Any Learning Difficulties? If yes, please elaborate.

Have Your difficulties been formally identified through the health board disability services? If Yes please elaborate

REFERENCES

Give the Names, Company, Position Address, Telephone and of Three Persons Not Related to You.
REFERENCE No. 1

REFERENCE No. 2

REFERENCE No. 3

ACKNOWLEDGMENT AND AUTHORIZATION

I certify that information contained in this application is true and complete to the best of my knowledge. I certify that I have not purposely withheld any information that might adversely affect my chances for hiring and therefore attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure can be grounds for rejection of application or, if I am employed by this company, terms for my immediate expulsion from the company. I understand that false or misleading information given in my application or interview(s) may result in discharge and may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I understand, also, that I am required to abide by all rules and regulations of the employer and I authorize the verification of any or all information listed above.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with any organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of the hiring organization.

I permit the company to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.

I Accept the Aaron and Margaret Wallace Foundation’s Terms of Submission. (Required)

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