Employment Application Employment ApplicationFull Name* First Name Middle Name Last Name Job Applying for:*Type*Full timePart timeTemporarySalary Desired:*Date Available:*PersonalAddress* Street Address City State / Province / Region ZIP / Postal Code Phone*Email* Are you a citizen of the United States?*YesNoIf no, are you authorized to work in the U.S.?*YesNoIf hired, can you furnish proof of eligibility?*YesNoCan you perform the essential function of the position for which you are applying?*YesNoHave you ever worked or attended school under another name?*YesNoIf yes, give details.*Have you ever worked for this organization?*YesNoIf yes, when?*Have you ever applied here before?*YesNoIf yes, when?*Are you presently employed?*YesNoIf yes, may we contact your current employer for a reference?*YesNoHave you ever been fired or asked to resign from a job?*YesNoHave you ever been convicted of a felony violation?*YesNoIf yes, give details*If employed by us, do you expect to be employed elsewhere?*YesNoIf yes, give details.*EducationHigh School or GED:*Address*From*To*Did you graduate?*YesNoDegree:*Vocational or Technical:*Address*From*To*Did you graduate?*YesNoDegree:*College or University:AddressFromToDid you graduate?YesNoDegree:Graduate School:AddressFromToDid you graduate?YesNoDegree:Other:AddressFromToDid you graduate?YesNoDegree:Do you have other skills or training that would be helpful for the job?YesNoIf yes, please explain.Employment HistoryPlease list employers starting with the current or most recent.Please explain gaps in employment.A job offer may be contingent on acceptable references from employers.Name of Employer:PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Supervisor’s Name:Title:Phone:Email Job Title:Ending Salary:Responsibilities:From:To:Reason for Leaving:May we contact your previous supervisor for a reference?YesNoName of Employer:Phone:Address Street Address City State / Province / Region ZIP / Postal Code Supervisor’s Name:Title:Phone:Email Job Title:Ending Salary:Responsibilities:From:To:Reason for Leaving:May we contact your previous supervisor for a reference?YesNoName of Employer:Phone:Address Street Address City State / Province / Region ZIP / Postal Code Supervisor’s Name:Title:Phone:Email Job Title:Ending Salary:Responsibilities:From:To:Reason for Leaving:May we contact your previous supervisor for a reference?YesNoVolunteer Activities and Professional MembershipsOrganization Name:Title:Responsibilities:Years Active:Organization Name:Title:Responsibilities:Years Active:Criminal History DisclosurePlease answer the following questions:Have you ever been arrested, cited, or detained by any law enforcement officer (including military police?)*YesNoHave you ever been charged with committing any crime or offense as a juvenile or adult?*YesNoHave you ever been convicted/found to have committed, pled guilty, or pled no contest to any crime or juvenile offense?*YesNoHave you ever been arrested for, charged with, convicted/found to have committed, pled guilty or pled no contest to a DUI or DWI?*YesNoHave you ever been placed in an alternative sentencing or rehabilitative program as a juvenile or an adult?*YesNoHave you ever been received a suspended sentence, been placed on probation, or been paroled?*YesNoHave you ever been in jail, prison, or a juvenile/youth detention facility?*YesNoHave you ever been in charged with the violation of a protection order?*YesNoHave you ever been listed on a sexual offender registry in any state?*YesNoHave you ever been listed in the TN Department of Health vulnerable persons registry?*YesNoIf you answered yes to any question, please explain:Check the box beside the statement:* I hereby certify that all the information provided in this employment application is true and complete. I understand that false information or the omission of information may disqualify my candidacy and may be grounds for termination. I further understand that I am applying to a Drug Free Workplace and may be required to submit to testing for the presence of drugs as a condition for employment. Signature*Date* Date Format: MM slash DD slash YYYY
