Yes No
Part Time Full Time Rotating Shifts
Evenings Weekends

Highest grade completed (circle)
1 2 3 4 5 6 7 8
9 10 11 12
Years Attended
1 2 3 4
Yes No
Other (Specify)
Years Attended
1 2 3 4
Yes No

(List Last or Present Position First)
Present and Former Employers
Dates Employed
Salary Range
Yes No

Yes No
Dates of duty
Yes No

Work References
You have been given a written job description listing the essential job functions of the position(s) for which you have applied. Please review the job description(s) and answer the following question. Are you able to perform each of the essential job functions listed for each position for which you have applied?
Yes No

(Please Read and Sign)

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.

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