Employment Application

Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, handicap or veteran status.

Date of Application:
Last Name: , First Name: Middle Initial:
Street Address:
City: , State: Zip:
Home Telephone:
Business Telephone:
Email Address:
Have you ever applied for employment with us? Yes No If Yes: Month and Year
Names of Relatives Employed by The Refuge:
Are you over the age of 18? Yes No
How were you referred? Advertisement Employee Friend Other
Position Desired: Pay Expected:
Full-Time Part-Time
When available for work? Are you available to work any shift? Yes No
Are you legally eligible to work in the United States? Yes No
Can you work overtime? Yes No
Have you eve been convicted of a crime, had adjudication of a crime withheld, or pled no contest to a crime? Yes No
If yes, please explain

Note: Answering 'Yes' to the question above may not necessarily disqualify you from the position desired. Each action and explanation will be weighted and considered in relationship to the position for which you are applying.

Education

School	Name and Location of School	Course of Study	No. of Years Completed	Did You Graduate?	Degree/Diploma
Elementary
High School
Business/Trade
College
Graduate

Licenses and Certifications

License/Certification Type and Number:
State: Current? Yes No
Other Certificates:

Employment

Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer.
Company Name:
Address:
Name of Supervisor:
Job Title:
Telephone:
Employed: From To
Weekly Pay: Start Last
Reason for leaving:
Describe your duties:

Company Name:
Address:
Name of Supervisor:
Job Title:
Telephone:
Employed: From To
Weekly Pay: Start Last
Reason for leaving:
Describe your duties:

Membership in Professional or Civic Organizations

Military
Did you serve in the U.S. Armed Forces? Yes No
If yes, What Branch?
Describe any training received relevant to the position for which you are applying?

Skills
Please describe any other experience, abilities, skills or credentials, which add to your qualifications

References

Reference Name:
Address:
Phone:
Years Known:
Relationship:

Person to Notify in Case of Emergency

Name:
Address:
Phone Number:
Alternate Number:

I UNDERSTAND that this application will only be considered active for 90 days from the date of application. If I have not obtained employment with The Refuge within 90 days, but remain interested in obtaining employment with The Refuge, I understand that I must complete a new application to be considered for employment. (Initial)

I ALSO UNDERSTAND that all statements made by me in connection with my application for employment may be checked by The Refuge and authorize them to contact my prior employers and other sources of information regarding my background, and I hereby authorize and direct such employer and source of information to answer any and all questions regarding my prior employers listed and each of the other sources of information contacted, and agree to hold them harmless from any claims arising from this authorization and direction. (Initial)

I UNDERSTAND further that any misstatements or omissions in this application will result in a decision not to hire me or to discharge me if discovered only after hire. (Initial)

I AGREE that, just as I have, if hired, the right to terminate my employment at any time, with or without cause, and with or without notice, The Refuge may terminate my employment at any time with or without cause or notice.

Applicant Signature:
Date:

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