Application for Employment

It is this facility's policy to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age or disability.

Present Address :

Are you at least 18 years old? ---YesNo

Position Applying For: ---Full TimePart TimePart Time per VisitPool

Shift: ---DayNightEveningWeekend

If you are not a US Citizen, have you the legal right to remain permanently in the US? ---YesNo

Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours? ---YesNo

Have you been convicted of a crime (example misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 7 years? ---YesNo

If Yes to above, please give date, place and nature of each such conviction.

Are you presently charged with any violation of the law other than traffic violation? ---YesNo

If Yes to above, give date, place and nature of each such conviction.

Education History

Last year attended: ---9101112

Did you graduate? ---YesNo

Last year attended: ---1234

Did you graduate? ---YesNo

Last year attended: ---1234

Did you graduate? ---YesNo

Last year attended: ---1234

Did you graduate? ---YesNo

List professional licenses you possess. Indicate type of license, number and state.

List any memberships in professional organizations, honors or activities which you feel would enhance your application, exlcuding those that would indicate race, color, religion, sex, national origin or disability.

List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc.