If you cannot be reached at above phone number, where may we contact you?
Professional Licenses and/or Certifications
List current (or most recent) employer first and all others in reverse chronological order.
Conviction of a criminal offense will not necessarily preclude your employment.
List three references who are not relatives or former employers.
Please indicate days and hours you are available for work (be specific).
I understand that emergency conditions may require me to temporarily work shifts other than the one for which
I am applying and agree to such scheduling change as directed by my department head or administrator of this institution.
If your availability status changes, it is your responsibility to notify your department head or the
administrator. Such changes will be effective then, for any future employment.
This institution does not discriminate in hiring or any other decision on the basis of race, color, sex,
citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental
disability unrelated to ability to perform the work required. No question on this application is intended to
secure information to be used for such discrimination.
I voluntarily give this institution the right to make a thorough investigation of my past employment and
activities, agree to cooperate in such investigation and release from all liability or responsibility all persons,
companies or corporations supplying such information. I consent to take the physical examination, and such future
physical examinations as may be required by this institution at such times and places as the institution shall
designate. I understand that an offer of employment may be contingent on passing the physical examination which
relates to the essential duties I would be required to perform.
I understand that my employment is at will, and that either party is free to terminate the employment
relationship at any time without cause. I also understand that my employment may be terminated for any
misstatement or omission of fact appearing on this application form.
If employed, I will be required to complete an Employment Verification Form (I-9) and within three days
show satisfactory evidence of identity and eligibility for employment.