"Employment Application Form - Domestic Violence Shelter & Services, Inc."

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DOMESTIC VIOLENCE SHELTER & SERVICES, INC.
PO Box 1555
Wilmington, NC 28402
910.343.0703 Phone / 910.343.9388 Fax
www.domesticviolence-wilm.org
(Application invalid without written signature and date)
We are an equal opportunity employer, dedicated to a policy of non-discrimination in recruitment, hiring,
compensation, fringe benefits, staff development, training, promotion and any other conditions of employment.
This agency does not discriminate based on race, color, religion, age, sex, national origin, political affiliation,
sexual identity, or any other non-performance factors.
Name:
Last
First
Middle
If employment or school was under a different name, indicate:
P
Permanent Address (No. & Street)
City
State
Zip Code
Tel. No. (incl. area code)
E
R
Present Address (No. & Street)
City
State
Zip Code
Tel. No. (incl. area code)
S
O
Tel. No. (incl. area code)
If not a U.S. citizen, do you have the legal right to remain permanently in the U.S.?
Yes
No
N
A
Have you ever been found guilty of, or
Position desired:
Valid Driver’s License?
Yes
No
convicted of, or plead no contest to a
L
criminal offense?
Yes
No
Access to a car while on duty?
Yes
No
List last two positions; show your most recent experience first:
Dates Employed
Title of position
Final salary
Reason for leaving
From
To
Mo.
Yr.
Mo.
Yr.
Employer’s name and address
Supervisor’s name, address and telephone number
E
M
P
Describe your primary responsibilities
L
O
Y
M
Dates Employed
Title of position
Final salary
Reason for leaving
E
From
To
N
Mo.
Yr.
Mo.
Yr.
T
Employer’s name and address
Supervisor’s name, address and telephone number
E
X
Describe your primary responsibilities
P
E
R
I
E
List additional employment experience
N
Dates employed from, to
Title of position
Name and address of employer
C
E
DOMESTIC VIOLENCE SHELTER & SERVICES, INC.
PO Box 1555
Wilmington, NC 28402
910.343.0703 Phone / 910.343.9388 Fax
www.domesticviolence-wilm.org
(Application invalid without written signature and date)
We are an equal opportunity employer, dedicated to a policy of non-discrimination in recruitment, hiring,
compensation, fringe benefits, staff development, training, promotion and any other conditions of employment.
This agency does not discriminate based on race, color, religion, age, sex, national origin, political affiliation,
sexual identity, or any other non-performance factors.
Name:
Last
First
Middle
If employment or school was under a different name, indicate:
P
Permanent Address (No. & Street)
City
State
Zip Code
Tel. No. (incl. area code)
E
R
Present Address (No. & Street)
City
State
Zip Code
Tel. No. (incl. area code)
S
O
Tel. No. (incl. area code)
If not a U.S. citizen, do you have the legal right to remain permanently in the U.S.?
Yes
No
N
A
Have you ever been found guilty of, or
Position desired:
Valid Driver’s License?
Yes
No
convicted of, or plead no contest to a
L
criminal offense?
Yes
No
Access to a car while on duty?
Yes
No
List last two positions; show your most recent experience first:
Dates Employed
Title of position
Final salary
Reason for leaving
From
To
Mo.
Yr.
Mo.
Yr.
Employer’s name and address
Supervisor’s name, address and telephone number
E
M
P
Describe your primary responsibilities
L
O
Y
M
Dates Employed
Title of position
Final salary
Reason for leaving
E
From
To
N
Mo.
Yr.
Mo.
Yr.
T
Employer’s name and address
Supervisor’s name, address and telephone number
E
X
Describe your primary responsibilities
P
E
R
I
E
List additional employment experience
N
Dates employed from, to
Title of position
Name and address of employer
C
E
Name and address
Dates attended (from-to)
Major Course of Study
Degree or Credits
Optional
E
D
High School
U
C
A
College/University
T
I
Graduate School
O
N
Technical or Business School
List recent training, as well as other courses, college, or graduate field work
T
R
Sponsoring organization and location
Description of training
No. Days
Year
A
I
N
I
N
G
Indicate your greatest skills and interests
S
K
I
L
L
S
List current professional memberships, volunteer and/or campus activities*
A
C
Name of organization
Location
Responsibilities
Dates
T
I
V
I
T
I
E
*If you prefer, you need not list any organization or activity that might indicate the race, color, creed, religion, national origin, age,
S
gender, political affiliation, sexual orientation, or any other non-performance factors.
Give the names of three persons (not related to you) who have definite knowledge of your qualifications.
R
E
Name
Address
Zip Code
Telephone
Position
Years Known
F
E
R
E
N
C
E
S
If your personal record is on file with a college placement office or other organization, provide the name and address of per son from whom it
may be secured.
 Yes
May we contact your present employer? (check one box)
No
I hereby certify that all statements are full and correct to the best of my knowledge and belief. I authorize investigation of all statements contained in this
application. I understand that willful misrepresentation or omission of facts may prevent my being hired and, if discovered after hiring, may be grounds for
immediate dismissal. I release all persons from liability resulting from obtaining and using the information. WRITTEN SIGNATURE REQUIRED.
Signature: __________________________________________________________________ Date: _________________________________________________________
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