Applicant Information

Last Name

First

M.I.

Date

Street Address

Apartment/Unit #

City

State

ZIP

Phone

E-mail Address

Date Available

Social Security No.

Desired Salary

Position Applied for

Are you a citizen of the United States?

YES 

NO 

If no, are you authorized to work in the U.S.?

YES 

NO 

Have you ever worked for this company?

YES 

NO  

If so, when?

Have you ever been convicted of a felony?

YES 

NO 

If yes, explain

Education

High School

Address

From

To

Did you graduate?

YES 

NO 

Degree

College

Address

From

To

Did you graduate?

YES 

NO 

Degree

Other

Address

From

To

Did you graduate?

YES 

NO 

Degree

References

Please list three professional references.

Full Name

Relationship

Company

Phone

(           )

Address

Full Name

Relationship

Company

Phone

(           )

Address

Full Name

Relationship

Company

Phone

(           )

Address

Previous Employment

Company

Phone

(           )

Address

Supervisor

Job Title

Starting Salary

$

Ending Salary

$

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

YES 

NO 

Company

Phone

(         )

Address

Supervisor

Job Title

Starting Salary

$

Ending Salary

$

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

YES 

NO 

Company

Phone

(         )

Address

Supervisor

Job Title

Starting Salary

$

Ending Salary

$

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

YES 

NO 

Military Service

Branch

From

To

Rank at Discharge

Type of Discharge

If other than honorable, explain

Disclaimer and Signature

I certify that the information given on this application and in any other supporting documentation and resume is true and correct.  I understand that any false information and/or willful negligent failure to disclose any requested information will constitute sufficient grounds to terminate my employment without notice.

I authorize my previous employers, schools, and persons named as references to give any information regarding my employment together with information they may have regarding me, whether or not it is in their records.  I agree that USD #316, Golden Plains and its employees and my previous employers and their employees shall not be held liable in any respect if an employment offer is not tendered, is withdrawn, or my employment is terminated because of false statements, answers, or omissions made by me in this application.  I hereby release said employers, schools, or persons from all liability for any damages whatsoever for issuing this information.

Signature

Date