DATE_____________________ INTERVIEWER_________________ A SMOKE & DRUG FREE FACILITY
APPLICANT INFORMATION: ARE YOU AN AMERICAN CITIZEN? ( ) YES ( ) NO
NAME: ___________________________________SOCIAL SECURITY NUMBER: ____-____-________
ADDRESS: ___________________________________________________________________________________________
HOME PHONE: ___________________________ WORK PHONE: _________________________________
I AM APPLYING FOR: _____Full time _____Full-time, Temporary _____Flexible Hours/On Call
______Part time _____Part-time, Temporary _____Weekends
POSITION WANTED:____ Receptionist _____Animal Care _____Clerical _____Laboratory _____Housekeeping _____Other (specify)
EDUCATIONAL BACKGROUND:
ARE YOU CURRENTLY A STUDENT ( ) YES ( ) NO WHERE___________________________________
High School_____________________________________ Graduated: ( ) Yes ( ) No ( ) GED
College_________________________________________ Graduated: ( ) Yes ( ) No DEGREE_________________
QUALIFICATIONS/OFFICE SKILLS:
Clerical: Typing WPM__________ COMPUTER SKILLS__________________________________________________________________________
WORK HISTORY: (Begin with most recent employment)
Employer: ______________________________________________________________________________ From_____/___ To_____/______
Address: ________________________________________________________________________________________________
Duties: ________________________________________________________________________Salary____________________
Reason For Leaving: ____________________________________________________________Hrs/Wk_____________________
Employer: ______________________________________________________________________________ From_____/___ To_____/___
Address: ________________________________________________________________________________________________
Duties: ________________________________________________________________________Salary____________________
Reason For Leaving: ____________________________________________________________Hrs/Wk___________________
Employer: _____________________________________________________________________________ From_____/___ To_____/___
Address: ________________________________________________________________________________________________
Duties: ________________________________________________________________________Salary____________________
Reason For Leaving: ____________________________________________________________Hrs/Wk___________________
Employer: ______________________________________________________________________________ From_____/___ To_____/___
Address: ________________________________________________________________________________________________
Duties: ________________________________________________________________________Salary____________________
Reason For Leaving: ____________________________________________________________Hrs/Wk___________________
Employer: ______________________________________________________________________________ From_____/___ To_____/___
Address: ________________________________________________________________________________________________
Duties: ________________________________________________________________________Salary____________________
Reason For Leaving: ____________________________________________________________Hrs/Wk___________________
REFERENCES: Full Name Home/Business Address Phone Number Occupation
1.______________________________________________________________________________________________________
2.______________________________________________________________________________________________________
3.______________________________________________________________________________________________________