Name of Applicant:
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Application Date:
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Name (Last)
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Name (First)
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Name (Middle)
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Name (Prefer to be called)
Physical Address (Street & No.)
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Physical Address (City)
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Physical Address (State)
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Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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
Physical AsZipcode
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Mailing Address (Street & No.)
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Mailing Address (City)
*
Mailing Address (State)
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Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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
Mailing Address (Zipcode)
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Telephone # (Home)
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Telephone # (Business)
Telephone # (Other)
Best time to contact you at home
Social Security #
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If yes, give date
If yes, give date
If yes, Name:
Relationship
If hired, when would you be able to start?
What hours and/or shift(s) would you prefer to work?
What hours and/or shift(s) would you prefer not to work?
Education- High School (School Name/Location)
Education- High School (# Yrs Completed)
Education- High School (Degree)
Education- High School (Study/Major)
Education- College/University (School Name/Location)
Education- College/University (# Yrs Completed)
Education- College/University (Degree)
Education- College/University (Study/Major)
Education- Graduate/Professional (School Name/Location)
Education- Graduate/Professional (# Yrs Completed)
Education- Graduate/Professional (Degree)
Education- Graduate/Professional (Study/Major)
Education- Trade/Correspondence (School Name/Location)
Education- Trade/Correspondence (# Yrs Completed)
Education- Trade/Correspondence (Degree)
Education- Trade/Correspondence (Study/Major)
Education- Other (School Name/Location)
Education- Other (# Yrs Completed)
Education- Other (Degree)
Education- Other (Study/Major)
If other, please explain:
Please describe any job-related specialized training you have had that is related to the position for which you are applying:
Do you hold any specialized licensure or certification (i.e.-Teacher certification, RN, LPN, CNA, CBA, CPA, etc.)?
(1) Present/Most Recent Employer Address:
(1) Present/Most Recent Employer Phone:
(1) Present/Most Recent Employer Position:
(1) Present/Most Recent Employer Hours Per Week:
(1) Present/Most Recent Employer From:
(1) Present/Most Recent Employer To:
(1) Present/Most Recent Employer Supervisor:
(1) Present/Most Recent Employer Reason For Leaving:
(1) Present/Most Recent Employer Duties & Responsibilities:
(2) Present/Most Recent Employer Address:
(2) Present/Most Recent Employer Phone:
(2) Present/Most Recent Employer Position:
(2) Present/Most Recent Employer Hours Per Week:
(2) Present/Most Recent Employer From:
(2) Present/Most Recent Employer To:
(2) Present/Most Recent Employer Supervisor:
(2) Present/Most Recent Employer Reason For Leaving:
(2) Present/Most Recent Employer Duties & Responsibilities:
(3) Present/Most Recent Employer Address:
(3) Present/Most Recent Employer Phone:
(3) Present/Most Recent Employer Position:
(3) Present/Most Recent Employer Hours Per Week:
(3) Present/Most Recent Employer From:
(3) Present/Most Recent Employer To:
(3) Present/Most Recent Employer Supervisor:
(3) Present/Most Recent Employer Reason For Leaving:
(3) Present/Most Recent Employer Duties & Responsibilities:
(4) Present/Most Recent Employer Address:
(4) Present/Most Recent Employer Phone:
(4) Present/Most Recent Employer Position:
(4) Present/Most Recent Employer Hours Per Week:
(4) Present/Most Recent Employer From:
(4) Present/Most Recent Employer To:
(4) Present/Most Recent Employer Supervisor:
(4) Present/Most Recent Employer Reason For Leaving:
(4) Present/Most Recent Employer Duties & Responsibilities:
If yes, please explain:
Why are you seeking a new position at this time?
Please explain fully any gaps in your employment history:
If yes, please explain:
List special knowledge, skills, abilities, and attributes you possess and believe relevant to the position you seek You may also list professional, trade, business activities and offices held or any additional information you feel may be helpful to us in considering your application.
How many jobs have you had in the last 5 years not listed above?
If yes, DL #
*
If "yes", please give dates and details of each:
Applicant's Attestations- I have reviewed the job description for the position for which I am applying, and am knowledgeable about the requirement of the job. I am capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the for which I have applied as delineated in the job description. I understand that if I am hired, my employment will be for no definite period, regardless of the period of payment of my wages. I further understand that I have the right to terminate my employment at will at any time with or without notice or reason, and HSNF has the same right. No one other than the Executive Director of HSNF has authority to modify this relationship or make any agreement to the contrary. Any such modification or agreement must be in writing. I understand that HSNF reserves the right to require me to submit to a drug test at any time and also reserves the right to require me to submit to an alcohol test and/or medical examination to the extent permitted by law. I further understand that HSNF may contact my previous employers and I authorize those employers to disclose to HSNF all records and other information pertinent to my employment with them. I release my previous employers from any liability as a result of their disclosure of information about me to HSNF. I also authorize HSNF to provide truthful information concerning my employment with it to my future prospective employers and I agree to hold it harmless for providing such information. I further understand that if employed I will be on a 90-day introductory period, and that termination for unsatisfactory performance during that period will not result in any HSNF responsibility for unemployment benefits. I further understand that completion of the introductory period does not confer any expectation of continued employment, and that if employed, my employment will be for no definite period and “at-will.” By signing this application, I certify that all of the information that I provide on this application and in any interview will be true, complete, and accurate. I understand that if I am employed and any such information is later found to be false or misleading in any respect, I will be dismissed. I certify that I am hereby notified that HSNF may obtain a consumer report or reports on me. I authorize HSNF to obtain such a report or reports for use in connection with my application for employment and for other employment-related reasons. If hired, this authorization shall remain on file and serve as ongoing authorization for procurement of employment-related consumer reports at any time during my employment. I understand that the term “consumer report” includes, but is not limited to, credit checks, criminal background checks, Department of Motor Vehicle reports, and investigative consumer reports. I authorize HSNF to conduct electronic inquiry related to my background, including review of all social networking sites and Internet sites and to make adverse decisions as a result of such inquiries. I further understand that the term “investigative consumer report” means a report in which information on my character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with my neighbors, friends, or associates, or with others with whom I am acquainted or who may have knowledge concerning any such items of information.
I Agree I DO NOT Agree
Full Name
Date
If you are human, leave this field blank.