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* = Required
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Date:*
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PERSONAL INFORMATION
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First Name:*
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Middle Name:
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Last Name:*
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Social Security Number:*
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Primary Phone #:*
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Secondary Phone/Cell:
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Present Address:*
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Present City:*
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Present State:*
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Present Zip:*
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Current Email:*
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In case of emergency notify:*
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Emergency Phone #:*
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Are you prevented from lawfully becoming employed in this country because of Visa
or Immigration status?*
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Are you 18 years or older?*
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EMPLOYMENT DESIRED
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Position:*
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Date you can start:*
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Annual Salary Desired:*
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Are you employed now?*
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If so, may we inquire of your present employer?*
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Have you ever applied to this organization before?*
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Where?
When?
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Have you ever worked for this organization before?*
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Where?
When?
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Reason for leaving:
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Name of last supervisor:
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Who referred you to this organization?*
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EDUCATION
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School Level
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Name & location of school
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# of years attended
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Graduated
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Grammar*
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Subjects studied:
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High School*
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Subjects studied:
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College (if applicable)
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Subjects studied:
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Other (if applicable)
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Subjects studied:
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GENERAL
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Special Training:
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Special Skills:
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Subjects of Special Study or Research Work:
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FORMER EMPLOYERS
(List below the last three employers, starting with the last one
first)
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Present or Immediate Past
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Name:
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Address:
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City:
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State:
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Zip:
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Start Date:
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Departure Date:
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Monthly Start Salary:
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Monthly End Salary:
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Job Title:
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May we contact your supervisor:
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Supervisor Name:
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Title:
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Supervisor Phone:
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Description of Work:
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Reason for leaving:
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Past Employer 2
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Name:
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Address:
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City:
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State:
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Zip:
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Start Date:
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Departure Date:
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Monthly Start Salary:
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Monthly End Salary:
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Job Title:
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May we contact your supervisor:
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Supervisor Name:
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Title:
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Supervisor Phone:
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Description of Work:
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Reason for leaving:
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Past Employer 3
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Name:
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Address:
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City:
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State:
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Zip:
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Start Date:
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Departure Date:
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Monthly Start Salary:
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Monthly End Salary:
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Job Title:
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May we contact your supervisor:
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Supervisor Name:
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Title:
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Supervisor Phone:
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Description of Work:
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Reason for leaving:
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REFERENCES
(List below the names of three people not related to you whom
you have known at least one year)
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Name*
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Address*
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Business*
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Years Acquainted*
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SERVICE RECORD
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Branch of Service:
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Discharge Date:
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Rank Obtained:
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Presently in Reserves or Branch:
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Date obligation ends:
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SPECIAL QUESTIONS
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DO NOT answer ANY of these questions in this framed area unless the
employer has checked the box with an X preceding the question. Thereby
indicating that the information is required for a bona fide occupational qualification
or is dictated by national security laws, or is needed for other legally permissible
reasons.
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XAre you a United States citizen?*
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XAre you able to perform each of the primary
duties and responsibilities for the position with or without an accommodation?*
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If you can perform the primary duties and responsibilities for the position with
an accommodation, explain how you would perform the tasks, and with what accommodations:
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XWhat foreign languages do you SPEAK fluently?
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XWhat foreign languages do you READ?
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XWhat foreign languages do you WRITE?
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XHave you been convicted of a felony or misdemeanor
within the last 5 years?*
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Describe:
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XI understand and agree that I may be required
to take one or more physical examination(s). I agree to consent to take such
test(s) at such time as designated in the Organization and to release the Organization,
its Directors, Officers, Agents or Employees from any claim arising in connection
with the use of such test(s).*
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Signature:
Date:
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* You will not be denied employment solely because of a
conviction record, unless the offense is related to the job for which you have applied.
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AUTHORIZATION
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I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND
COMPLETE, AND I UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS
ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I AM EMPLOYED, MY EMPLOYMENT
MAY BE TERMINATED AT ANY TIME. IN CONSIDERATION OF MY EMPLOYMENT, I AGREE
TO CONFORM TO THE ORGANIZATION'S RULES AND REGULATIONS, AND I AGREE THAT MY EMPLOYMENT
AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE,
AT ANY TIME, AT EITHER MY OR THE ORGANIZATION'S OPTION. I ALSO UNDERSTAND AND AGREE
THAT THE TERMS AND CONDITIONS OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE
AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE ORGANIZATION. I UNDERSTAND THAT NO
ORGANIZATION REPRESENTATIVE OTHER THAN ITS PRESIDENT, AND THEN ONLY WHEN IN WRITING
AND SIGNED BY THE PRESIDENT, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT
FOR ANY SPECIFIC PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.
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Revision 06-05
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