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Online Employment Application

To download and print an application, please click here for the PDF formatted version.

** denotes a required field

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status. We are a tobacco free campus. We do not hire people who smoke or use tobacco products.
Position(s) Applied For**: Date of Application**:
How did you hear about us? Advertisement Relative Inquiry
Employment Agency Friend Other (Please List)
Last Name**:
First Name**:
M.I.:
Email:
Address**:
City**:
 : 		State**:
Zip**:
Daytime Phone #:
( ) 		Evening Phone #**:
( ) 		Social Security Number: (optional)
- -
Best time to contact you at home is: :
If you are under 18 years of age, can you provide proof of your eligibility to work? Yes No
Have you ever filed an application with us before? Yes No
If yes, give date:
Have you even been employed with us before? Yes No
If yes, give date:
Do any of your friends or relatives, other than spouse, work here? Yes No
Are you currently employed? Yes No
If yes, may we contact your present employer? Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment. Yes No
Are you currently on "lay-off" status and subject to recall? Yes No
Do you smoke or use tobacco products? Yes No
Can you travel if your job requires it? Yes No
Have you been convicted of a felony within the last 7 years? Yes No
Are you available to work:
Full-Time 1st Shift 2nd Shift 3rd Shift
Part-Time Mornings Afternoons Evenings
Temporary -
Please indicate dates available: through
Employment Experience
Start with your present or last job. Include any job related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, national origin, disabilities or other protected status.
- 1 -
Employer:
Dates Employed:
 Work Performed:
Address: (Street, City, ST - ZIP)
 From:
To:
Telephone Number(s):
Hourly Rate/Salary
Job Title:
Supervisor:
Starting:
 		Final:
Reason for leaving:
- 2 -
Employer:
Dates Employed:
 Work Performed:
Address: (Street, City, ST - ZIP)
From:
To:
Telephone Number(s):
Hourly Rate/Salary
Job Title:
Supervisor:
Starting:
Final:
Reason for leaving:
- 3 -
Employer:
Dates Employed:
 Work Performed:
Address: (Street, City, ST - ZIP)
From:
To:
Telephone Number(s):
Hourly Rate/Salary
Job Title:
Supervisor:
Starting:
Final:
Reason for leaving:
- 4 -
Employer:
Dates Employed:
 Work Performed:
Address: (Street, City, ST - ZIP)
From:
To:
Telephone Number(s):
Hourly Rate/Salary
Job Title:
 		Supervisor:
Starting:
Final:
Reason for leaving:
Education
  School Name School Location
(City, ST)		 Course of Study No. of Years
Completed 		Diploma/
Degree
Elementary School
#####

#####
High School
#####
Undergraduate College
Graduate/
Professional
Other (Specify)
Additional Information
Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.
Specialized Skills
(Check Skills or Equipment you have operated)
Terminal Spreadsheet
Production/Mobile
Machinery (list)

Other (list)
PC/Mac Word Processing
Typewriter WPM
 Shorthand WPM
Note to Applicant: Do not answer this question unless you have been informed about the requirements of the job for which you are applying.
Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been given.
Yes No
List professional, trade, business or civic activities and offices held. You many exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:
References
- 1 -
Name:
 Phone:
  
Street Address:
 City:
 ST:
 ZIP:
- 2 -
Name:
 Phone:
  
Street Address:
 City:
 ST:
 ZIP:
- 3 -
Name:
 Phone:
  
Street Address:
 City:
 ST:
 ZIP:
- 4 -
Name:
 Phone:
  
Street Address:
 City:
 ST:
 ZIP:
Applicant Statement

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 90 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 this organization is of an "at will" employment relationship and may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

I AGREE I DISAGREE
(By checking "I AGREE", I verify the above "Applicant's Statement" is true.)
HAVE YOU BEEN EXCLUDED FROM PARTICIPATION IN MEDICAID/MEDICARE BECAUSE OF FRAUD CONVICTION? YES NO
   
 
 
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