"Employment Application Form" - Georgia (United States)

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EMPLOYMENT APPLICATION
PARTICIPANT’S NAME: ______________________________
PERSONAL INFORMATION:
APPLICANT’S NAME:
DATE: ________________________
STREET ADDRESS: ___________ __________________
CITY: __________ ______________
STATE:
ZIP:
SOCIAL SECURITY #:
HOME PHONE NUMBER:
OTHER:
E-MAIL ADDRESS:
____________________
_
EMPLOYMENT ELIGIBILITY:
To be employed with the State of Georgia, you must meet certain State and Federal employment eligibility
requirements. These include, but are not limited to, United States citizenship or authorization to work in this
country, and no felony convictions.
Are you interested in serving as a (check all that apply):
Full-time employee?
Part-time employee?
Backup employee?
Are you currently employed:
___YES
NO
Date available for employment:
How many hours a week can you work?
Are you 18 years of age or older?
___YES
NO
Are you a United States citizen?
___YES
NO
Are you an alien authorized to work in the United States? ___YES
NO
GEORGIA LICENSES AND CERTIFICATIONS:
Do you have a valid driver's license?
___YES
NO
Do you have current First Aid Certification*?
___YES
NO
if yes, expiration date: ______________
Do you have current CPR Certification*?
___YES
NO
if yes, expiration date: ______________
Do you have Nurse Aide Certification?
___YES
NO
if yes, expiration date: ______________
Please list any other professional certifications:
* If hired, you must provide a copy of your current CPR card and First Aid card to your employer.
EDUCATION:
High School Graduate or equivalent (GED)? ___YES
NO
Vocational/Business School?
___YES
NO
if yes, field of study:
# of months:
completion date:
College? ___YES
NO
College Graduate?
___YES
NO
if yes, degree:
completion date:
LIST THREE PERSONAL REFERENCES:
(Name)
(Address)
(Phone Number)
(Name)
(Address)
(Phone Number)
(Name)
(Address)
(Phone Number)
EMPLOYMENT APPLICATION
PARTICIPANT’S NAME: ______________________________
PERSONAL INFORMATION:
APPLICANT’S NAME:
DATE: ________________________
STREET ADDRESS: ___________ __________________
CITY: __________ ______________
STATE:
ZIP:
SOCIAL SECURITY #:
HOME PHONE NUMBER:
OTHER:
E-MAIL ADDRESS:
____________________
_
EMPLOYMENT ELIGIBILITY:
To be employed with the State of Georgia, you must meet certain State and Federal employment eligibility
requirements. These include, but are not limited to, United States citizenship or authorization to work in this
country, and no felony convictions.
Are you interested in serving as a (check all that apply):
Full-time employee?
Part-time employee?
Backup employee?
Are you currently employed:
___YES
NO
Date available for employment:
How many hours a week can you work?
Are you 18 years of age or older?
___YES
NO
Are you a United States citizen?
___YES
NO
Are you an alien authorized to work in the United States? ___YES
NO
GEORGIA LICENSES AND CERTIFICATIONS:
Do you have a valid driver's license?
___YES
NO
Do you have current First Aid Certification*?
___YES
NO
if yes, expiration date: ______________
Do you have current CPR Certification*?
___YES
NO
if yes, expiration date: ______________
Do you have Nurse Aide Certification?
___YES
NO
if yes, expiration date: ______________
Please list any other professional certifications:
* If hired, you must provide a copy of your current CPR card and First Aid card to your employer.
EDUCATION:
High School Graduate or equivalent (GED)? ___YES
NO
Vocational/Business School?
___YES
NO
if yes, field of study:
# of months:
completion date:
College? ___YES
NO
College Graduate?
___YES
NO
if yes, degree:
completion date:
LIST THREE PERSONAL REFERENCES:
(Name)
(Address)
(Phone Number)
(Name)
(Address)
(Phone Number)
(Name)
(Address)
(Phone Number)
LIST PREVIOUS JOBS YOU HAVE HAD (BEGINNING WITH MOST RECENT):
EMPLOYER’S NAME:
DATES OF EMPLOYMENT:
EMPLOYER’S ADDRESS:
SUPERVISOR’S NAME:
PHONE NUMBER:
LIST OF JOB DUTIES:
REASON FOR LEAVING:
EMPLOYER’S NAME:
DATES OF EMPLOYMENT:
EMPLOYER’S ADDRESS:
SUPERVISOR’S NAME:
PHONE NUMBER:
LIST OF JOB DUTIES:
REASON FOR LEAVING:
EMPLOYER’S NAME:
DATES OF EMPLOYMENT:
EMPLOYER’S ADDRESS:
SUPERVISOR’S NAME:
PHONE NUMBER:
LIST OF JOB DUTIES:
REASON FOR LEAVING:
BRIEFLY LIST REASONS YOU SHOULD BE CONSIDERED FOR THIS JOB:
APPLICANT ACKNOWLEDGEMENT
You ___may ____may not contact my current employer. If not, reason:
If offered a position, will you be able to be at work on time and according to the schedule discussed? __ Yes ___ No
Comments:
I, ____________________________(print name), the applicant, certify that the information provided is true and correct to
the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is
sufficient cause for refusal to hire, or dismissal if employer has employed me, no matter when discovered by employer. I
also acknowledge that a background check is required and that some convictions prevent employment.
I authorize this potential employer to investigate all statements contained in this application, and I authorize my former
employers and references to disclose information regarding my former employment, character and general reputation,
without giving me prior notice of such disclosure.
I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create
an employment contract. I further understand and agree that if I am hired, my employment will be “at will” and without
fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself
or this employer. No promises regarding employment have been made to me, and I understand that no such promise or
guarantee is binding upon this employer unless made in writing.
Signature:
Date:
GA
Rev. 09/18/13
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