Form 09-05

PLEASE PRINT LEGIBLY

 

 

An Equal Opportunity Employer

Application for Employment

Employees of xxx and applicants for employment shall be afforded equal opportunity in all aspects of employment without regard to race, color, religion, political affiliation, national origin, disability, marital status, gender or age.

    As a means of accommodation to persons with specific disabilities that prevent them from completing this application, confidential assistance in filling out this application may be obtained by calling the company directly.
1. Position applied for 2. Referred
 

(one per application)

  
   
3. Social Security No.
     
4. Full legal name

6. Home Phone ()
 

Last

First

Middle

    
5. Address 7. Business Phone ()

8. E-mail Address
 

City

State

Zip

  
9. EDUCATION
1 2 3 4 5 6 7 8 9 10 11 12

    b. If you did not complete high school, do you have a high school equivalency diploma?

 Yes No

    c. Check number of years of post high school education

 1 2 3 4 5 6 7
 

    Name and Location of Institution

Hrs

Degree Received

Major or Specialty

Minor

Dates Attended

    1.

    2.

    3.

    d. If you expect to complete an educational program in the near future, please indicate what type of degree or program and expected

    completion date:

    10. EXPERIENCE — Use Supplementary Experience Form(s) for additional space. 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? Yes No
a. Job Title Duties:

    Employer

    Address
Phone

    Type of business

    Immediate supervisor

      Title

 Number and titles of employees you supervised

    Salary (start)

 (finish) Equipment used

    Dates (mo/yr)

 to (mo/yr) Reason for leaving

    Full-time

 Part-time Hours/week Your name if different from present
b. Job Title Duties:

    Employer

    Address
Phone

    Type of business

    Immediate supervisor

      Title

 Number and titles of employees you supervised

    Salary (start)

 (finish) Equipment used

    Dates (mo/yr)

 to (mo/yr) Reason for leaving

    Full-time

 Part-time Hours/week Your name if different from present
c. Job Title Duties:

    Employer

    Address
Phone

    Type of business

    Immediate supervisor

      Title

 Number and titles of employees you supervised

    Salary (start)

 (finish) Equipment used

    Dates (mo/yr)

 to (mo/yr) Reason for leaving

    Full-time

 Part-time Hours/week Your name if different from present
d. Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops,

    and special achievements or specialized skills:
e. Automated word processing (specify equipment)

    Typing speed

words per minute. Shorthand speed

words per minute
f. License (to include driver’s), certificate or other authorization to practice a trade or profession.
  Type

License Number

Granted by (licensing board)
11. REFERENCES

    List names, addresses and relationships of three persons not related to you who know your qualifications:
 

Name

Address

Phone

Relationship
12. MISCELLANEOUS
a. Check which shift you will accept: Day Evening Night Rotating Weekends Specify shift hours
b. Check which job status you will accept: Full-time Part-time (specify)
c. Check which employment status you will accept: Salaried Hourly Part-time salaried
d. Are you willing to provide your own transportation if necessary for your employment? Yes No.
e. For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States?

    Yes No. 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.
f. Have you ever been convicted* for any violation(s) of law, including moving traffic violations. Yes No If YES, please provide the following:

    Description of offense:

    Statute or ordinance (if known ): Date of Charge: ; Date of Conviction

    County, City, State of Conviction:
(For additional convictions use plain paper. Include all information listed above.)
13. When will you be available to start work? (No date is necessary if you are available as soon as you give two (2) weeks notice.)
Month Day Year
14. CERTIFICATION--Each Application Requires Current Date and Original Signature

    I hereby certify that all entries on both sides and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment in the service of FCHP, INC. 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 FCHP, INC. to rely upon and use, as it sees fit, any information received from such contacts. Information contained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a need-to-know basis for good cause shown as determined by the agency head or designee.

     

     

    Date

 Applicant Signature

 

 

 

 

 

 

 

 

 

Supplementary Experience Form

 
Social Security Number Position Applied For
Name  

 
Job Title Duties:

    Employer

    Address
Phone

    Type of business

    Immediate supervisor

      Title

 Number and titles of employees you supervised

    Salary (start)

 (finish) Equipment used

    Dates (mo/yr)

 to (mo/yr) Reason for leaving

    Full-time

 Part-time Hours/week Your name if different from present
Job Title Duties:

    Employer

    Address
Phone

    Type of business

    Immediate supervisor

      Title

 Number and titles of employees you supervised

    Salary (start)

 (finish) Equipment used

    Dates (mo/yr)

 to (mo/yr) Reason for leaving

    Full-time

 Part-time Hours/week Your name if different from present
Job Title Duties:

    Employer

    Address
Phone

    Type of business

    Immediate supervisor

      Title

 Number and titles of employees you supervised

    Salary (start)

 (finish) Equipment used

    Dates (mo/yr)

 to (mo/yr) Reason for leaving

    Full-time

 Part-time Hours/week Your name if different from present
Job Title Duties:

    Employer

    Address
Phone

    Type of business

    Immediate supervisor

      Title

 Number and titles of employees you supervised

    Salary (start)

 (finish) Equipment used

    Dates (mo/yr)

 to (mo/yr) Reason for leaving

    Full-time

 Part-time Hours/week Your name if different from present
Job Title Duties:

    Employer

    Address
Phone

    Type of business

    Immediate supervisor

      Title

 Number and titles of employees you supervised

    Salary (start)

 (finish) Equipment used

    Dates (mo/yr)

 to (mo/yr) Reason for leaving

    Full-time

 Part-time Hours/week Your name if different from present