|
First Name: |
|
Last Name: |
|
| Address |
|
| City: |
|
State: |
|
| Zip: |
|
Phone: |
|
| E-mail: |
|
Mailing address:
(if different) |
|
| Desired Position: |
|
Date available for work: |
|
| Other Positions for which you may qualify: |
|
Available for (check all applicable)
F/T
P/T
TEMP |
Social Security No: |
|
Can you travel locally if job requires?
Yes
No |
Nearest public transportation |
|
Are you 18 years of age or older
Yes
No
If No, state your age |
Are you legally eligible to work in the United States?
Yes
No |
| Is additional information relative to name change necessary to enable a check of your work/school records?
Yes
If Yes, state your name
No |
How were you referred to Selfhelp?
Advertisement
Friend
Relative
School
Other, please state
|
| Insert Resume
(In order to submit your resume, open the word document containing your resume. Highlight the entire resume text and select Ctrl & the Letter C (at the same time). Return to your browser and the Selfhelp application form. Click on text box below and then select Ctrl and the Letter V (at the same time). The box has space for up to two pages.)
|
| |
|
|
|
|
|
Have you previously applied to Selfhelp?
Yes
No
If yes, give details, dates
department
|
Were you previously employed by Selfhelp?
Yes
No
If yes, give details, dates
department
|
Have you ever been convicted of a felony?
Yes
No
If yes, give date (s)
and charge (s)
Note: your application will not be summarily rejected because of your record. Various mitigating factors will be considered. If employment is denied you have a right to request and receive a written statement setting fourth reasons for such denial. |
List any relatives currently employed at Selfhelp (will not restrict hiring except in assignment to same department):
|
| List professional or technical license # applicable to position: |
| Type:
License #:
Date Expires:
|
|
| If you have any job-related volunteer experience which would contribute to your qualifications, please indicate below. You may exclude organizations which indicate race, color, gender, national origin, disability, citizenship status, sexual orientation, marital status, sex, age or other protected status. |
| Dates |
Organization: |
Responsibilities |
|
|
|
|
|
|
|
|
|
|
|
|
Employment History
THIS SECTION MYST BE COMPLETED
Start with your current or last job, include any military service
|
| Employer #1 |
| Employer: |
|
Address/City: |
|
| From (MM/YYYY): |
|
To (MM/YYYY): |
|
| Supervisor: |
|
Phone: |
|
| Salary: |
Starting $
per
|
| Final $
per
|
| Job Title : |
|
| Reason for Leaving: |
|
| Brief Description of Duties: |
|
| Employer #2 |
| Employer: |
|
Address/City: |
|
| From (MM/YYYY): |
|
To (MM/YYYY): |
|
| Supervisor: |
|
Phone: |
|
| Salary: |
Starting $
per
|
| Final $
per
|
| Job Title : |
|
| Reason for Leaving: |
|
| Brief Description of Duties: |
|
| Employer #3 |
| Employer: |
|
Address/City: |
|
| From (MM/YYYY): |
|
To (MM/YYYY): |
|
| Supervisor: |
|
Phone: |
|
| Salary: |
Starting $
per
|
| Final $
per
|
| Job Title : |
|
| Reason for Leaving: |
|
| Brief Description of Duties: |
|
| Employer #4 |
| Employer: |
|
Address/City: |
|
| From (MM/YYYY): |
|
To (MM/YYYY): |
|
| Supervisor: |
|
Phone: |
|
| Salary: |
Starting $
per
|
| Final $
per
|
| Job Title : |
|
| Reason for Leaving: |
|
| Brief Description of Duties: |
|
| |
|
**Please read carefully before submitting your application**
I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery. I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Selfhelp that such employment with Selfhelp is at will, for no specified duration and may be terminated by either Selfhelp or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, or statements of Selfhelp or its representatives used during the employment process is deemed a contract of employment, real or implied. I understand that no representative of Selfhelp except the CEO has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the CEO of Selfhelp. I understand that if offered a position with Selfhelp, I may be required to submit to a pre-employment medical examination, drug screening and background check as a condition of employment. I understand that unsatisfactory results, refusal to cooperate with, or any attempt to affect the results of these pre-employment tests and checks will result in withdrawal of any employment offer or termination of employment if already employed. I hereby authorize any and all schools, former employers, references, courts, and any others who have information about me to provide such information to Selfhelp and/or any of its representatives, agents, or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that this application is considered current for three months. If I wish to be considered for employment after this period I must fill out and submit a new application. .
By checking this box, I acknowledge that I have read, understood, and agree to the above statements. |
|
