An Equal Opportunity Employer
Personal
Social Security No._______________________________________________ Date _________________________________________________
Last Name___________________________________________ First_______________________ Telephone No.___________________________
Present address __________________________________________________________________Rate of Pay expected $____________________
Would you work ______Full-time ______Part-Time Specify days and hours if part-time______________________________________________
Were you previously employed by this organization? ______ If yes, when?_________________________________________________________
List any friends or relatives working here, other than spouse______________________________________________________________________
If your application is considered favorably, on what date will you be available for work?_______________________________________________
Are there any other work experiences, skill, or qualifications that you feel would especially fit you for work here? Please add any additional
comments you think are important for us to consider. ___________________________________________________________________________
_________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
If you are applying for a job with minimum age requirements, you may be required to submit proof of age.
Are you 18 years of age or older?_____________________________________________________________
For driving jobs only: Do you have a valid driver's license?___________________________________________________________________________________
Driver's license number______________________________________________________________________
Have you had your driver's license revoked or suspended in the last 3 years?______________________________________________________________________
If hired, can you furnish proof you are eligible to work in the United States?____________________________________________________________
Have you ever been convicted of a felony_______________________________________________________________________________________
A"yes" answer does not automatically disqualify you from employment since the nature of the offense, date and job for which you are apply will be considered.
If yes, please explain__________________________________________________________________________________________________________
Have you previously applied here?_____________________________________________________________________________________________
If yes, when?________________________________________________________________________________________
Have you worked for any firm under a different name?_____________________________________________
If yes, give name ____________________________________________________________________________________
Personal References (not former employers or relatives)
Name and occupation Address Phone number
1)
_____________________________________________________________________________________________________________________________________
2)
____________________________________________________________________________________________________________________________________
3)
____________________________________________________________________________________________________________________________________
Membership in Professional or Civic Organizations (do not include racial religious, or nationality groups)
Name or description of organization__________________Active participation Offices held___________________________
1)
2)
3)
Education Record - Non veterinarians Only
Name of school Degree awarded Grade average Honors
_________________________________________________________________________________________________________________________________
High School
__________________________________________________________________________________________________________________________________
College or University
__________________________________________________________________________________________________________________________________
Business, Trade, Correspondence or Night School
__________________________________________________________________________________________________________________________________
Other
__________________________________________________________________________________________________________________________________
Work History (begin with the most recent, list all past employers, including any pertinent military experience)
Name of Company Business address City State Phone number
Type of business Immediate supervisor Date employed From To
Exact job title Earnings at hire At termination Reason for termination
Description of duties
Name of Company Business address City State Phone number
Type of business Immediate supervisor Date employed From To
Exact job title Earning at hire At termination Reason for termination
Description of duties
________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Name of Company Business address City State Phone number
Type of business Immediate supervisor Date employed From To
Exact job title Earning at hire At termination Reason for termination
Description of duties
I certify that all information I have provided in this application is true and complete. I understand that any false information or omission may disqualify me from
further consideration for employment and may result in my dismissal if discovered at a later date. I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.
I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME, IF EMPLOYED, UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE.
I have read, understand and by signature consent to these statements.
Signature Date
