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Date of Application *

Available Start Date *

Position(s) applied for *

Referral Source *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Are you 18 years of age or older? *

Yes No

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? *

Yes No

Will you need a reasonable accommodation for the hiring process? *

Yes No

Do you satisfy the physical qualifications as required in position description? *

Yes No

Available Work Schedule *

Have you previously been an employee at L.E. Phillips Career Development Center? *

Yes No

Are you on lay-off and subject to recall? *

Yes No

Can you travel if the job requires it? *

Yes No

Do any of your friends or relatives (other than your spouse) work here? *

Yes No

Have you been convicted of a felony within the last seven (7) years? *

Yes No

List any professional, trade, business or civic activities and offices held (exclude groups which indicate race, color, religion, national origin, or gender) *

Street Address *

State *

Military Status: Active Duty Service From: *

To: *

Branch of Service *

Service Duties *

Are you a member of a Reserve organization? *

Employer #1 *

Position Held *

Supervisor *

Wages - Starting to Final *

Employment Dates - From : To *

Essential Job Functions *

Reason for Leaving *

May we contact this employer? *

Yes No

Employer #2 *

Position Held *

Supervisor *

Employment Dates - From : To *

Wages - Starting to Final *

Essential Job Functions *

Reason for Leaving *

May we contact this employer? *

Yes No

Employer #3 *

Untitled *

UAddress *

Supervisor *

Phone *

Wages - Starting to Final *

Employment Dates - From : To *

Essential Job Functions *

Reason for Leaving *

May we contact this employer? *

Yes No

High School Name & Location *

Course of Study *

Years Completed *

Graduated? *

College Name & Location *

Course of Study *

Years Completed *

Graduated? *

Graduate School Name & Location *

Course of Study *

Years Completed *

Graduated? *

List any honors you have received: *

Describe any specialized training, apprenticeship, skills and extra - curricular activities that you may have had or been involved in: *

Government contractors are subject to Section 402 of the Vietnam Era Veterans Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified handicapped individuals. If you are a disabled veteran, or have a physical or mental handicap, you are invited to volunteer this information. This purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job in a proper and safe manner. This information will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect any consideration you may receive for employment. If you wish to be identified, please select the appropriate category below: *

I certify that the answers given herein are true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts in this application may result in discharge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. If employed, I understand that such employment may be terminated at anytime, without prior notice, and will not be governed by any expressed or implied contract but at-will. I also understand that I am required to abide by all rules and regulations of the company. *

I Agree to these terms

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