Online Employment Application

Position Applying For
 Name & address of former employer
Name *

A name is required.
Phone *

A phone number is required. 		Supervisor
Email *

An email address is required. 		Dates employed (from/to)
Other Phone
 Salary (start/end)
Reason for leaving
 Position held
If presently employed, why do you desire to change your position?
 Are you able to perform the specific job tasks with or without reasonable accommodation?
Yes   No
If you are able to perform one or more of the job functions with reasonable accommodation, please describe how you would perform the tasks and with what accommodation?
 Can you meet the attendance requirements of the job?
Yes   No
 

EDUCATION
Level of Education Name Address Major Last Year Completed Degree
High
School		  1
 2
 3
 4
Business
School		  1
 2
 3
 4
College  1
 2
 3
 4
Graduate
Work		  1
 2
 3
 4
Are you planning to pursue further studies?
Yes   No 		Do you speak French fluently?
Yes   No
If so, when, where, and what courses?
 

PERSONAL REFERENCES


Please list the names of three personal references who have known you well during the past FIVE or more years. You may include the names of friends or acquaintances presently employed by us but do not list relatives, former employers or fellow employees.
Name Address No. of Years
Acquainted		 Phone Number
Have you ever been convicted of a criminal offense involving dishonesty or breach of trust (including but not limited to, robbery, larceny, shoplifting, embezzlement, forgery, perjury, tax evasion, etc.)?
Yes   No
 

PLEASE READ BEFORE SUBMITTING


I certify the facts set forth in my application for employment are true and complete. I understand, if employed, false statements or materials omissions on this application may result in my dismissal. I authorize the company to verify all statements contained in this application and to make any necessary reference checks and checks with prior employers.


I authorize the references and employers listed above to give the company any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and I release the employers and references I have listed, as well as the company, from liability from any damages which may result from furnishing the same to the company.


If employed, I agree to conform to all the policies and procedures of the company and recognize that my employment and compensation can be terminated with or without cause, and without notice at any time at the option of either the company or myself.


I understand that no representative of the company, other than the Executive Director and the Chairman of the Board acting together and in writing, has any authority to enter into an agreement for employment for a specified period of time or to make any agreement contrary to this paragraph.


By submitting this form, I agree to the above terms and conditions.
Date
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