Employment Application Form

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HR 2/12
EMPLOYMENT APPLICATION
DATE ____________________
Mo
Day
Yr
EMPLOYER: _______________________________
APPLYING FOR __________________________________ POSITION
WORKSTUDY ELIGIBLE? YES NO
(Example: Cashier, Secretary, Maintenance
(circle yes or no)
PRINT CLEARLY
NAME_________________________________________________________________
______________________
Last
First
Middle
T Number
ADDRESS__________________________________________________________ (_____)______________________
Number
Street
Apt #
Phone Number
___________________________________________________________________ (_____)______________________
City
State
Zip Code
Alternate Phone
E-Mail ___________________________
Morning
Afternoon
Night
Weekends
EMPLOYMENT SOUGHT
: _______________________________________________________________________
HOURS AVAILABLE
(Example: M W F 10:00 to 2:00, Sat. 8:00 to 5:00, etc.)
_____________________________
DATE YOU CAN START
ARE YOU EMPLOYED NOW? YES NO IF SO, MAY WE CONTACT YOUR PRESENT EMPLOYER? YES NO
EDUCATION
College, Trade School
Major/Minor
Year in School
When will you
Name and City Location
Fr, Soph, Jr, Sr
graduate? Mo./Yr.
Southern Utah University
Cedar City, UT
QUALIFICATIONS AND SKILLS: Computer (software) programs, Tools, Equipment, Related skills, Certificates
(and any other traits that would make you a good employee) etc.
Continued on Other Side
HR 2/12
EMPLOYMENT APPLICATION
DATE ____________________
Mo
Day
Yr
EMPLOYER: _______________________________
APPLYING FOR __________________________________ POSITION
WORKSTUDY ELIGIBLE? YES NO
(Example: Cashier, Secretary, Maintenance
(circle yes or no)
PRINT CLEARLY
NAME_________________________________________________________________
______________________
Last
First
Middle
T Number
ADDRESS__________________________________________________________ (_____)______________________
Number
Street
Apt #
Phone Number
___________________________________________________________________ (_____)______________________
City
State
Zip Code
Alternate Phone
E-Mail ___________________________
Morning
Afternoon
Night
Weekends
EMPLOYMENT SOUGHT
: _______________________________________________________________________
HOURS AVAILABLE
(Example: M W F 10:00 to 2:00, Sat. 8:00 to 5:00, etc.)
_____________________________
DATE YOU CAN START
ARE YOU EMPLOYED NOW? YES NO IF SO, MAY WE CONTACT YOUR PRESENT EMPLOYER? YES NO
EDUCATION
College, Trade School
Major/Minor
Year in School
When will you
Name and City Location
Fr, Soph, Jr, Sr
graduate? Mo./Yr.
Southern Utah University
Cedar City, UT
QUALIFICATIONS AND SKILLS: Computer (software) programs, Tools, Equipment, Related skills, Certificates
(and any other traits that would make you a good employee) etc.
Continued on Other Side
WORK HISTORY
Begin with present or most recent, list your two most significant employers, if you wish to elaborate, a supplemental sheet
or resume may be attached. Include military service if applicable.
FIRM NAME
DATES From:
To:
ADDRESS
REASON FOR LEAVING
JOB TITLE:
SUPERVISOR’S NAME
RESPONSIBILITIES AND DUTIES:
FIRM NAME
DATES From:
To:
ADDRESS
REASON FOR LEAVING
JOB TITLE:
SUPERVISOR’S NAME
RESPONSIBILITIES AND DUTIES:
Have you ever been convicted of a felony? YES / NO. If yes, please explain when, where, and final disposition:
_____________________________________________________________________________
_____________________________________________________________________________
Have you ever been convicted of a Class A misdemeanor? YES / NO. If yes, please explain when, where and final
disposition: _________________________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
REFERENCES
Name/Job Title
Business / Occupation
City and State
Telephone
CERTIFICATION OF APPLICANT
I CERTIFY THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE TRUE AND CORRECT, AND THAT
ANY MISSTATEMENT OF MATERIAL FACTS MAY SUBJECT ME TO DISQUALIFICATION OR DISMISSAL.
ALSO, I AUTHORIZE INVESTIGATION OF ALL STATEMENTS MADE IN THIS APPLICATION.
Signature_____________________________________________________
Date_______________________

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