Employment Application

Personal Iinformation

First Name:
Middle Initial:
Last Name:
Position applied for:
Availability Date"
Expected rate of pay"
Mailing Address
City:
State:
Zip:
Home Phone:
Work
Email:
Are you: over 18
over 25 (some positions have min. age requirements)
Are you a U.S. Citizen?     Yes No
if no, do you have a work authorization number? Yes No
Have you applied for employment with this firm in the past?    Yes No
Are you interested in working full- or part-time?     Full-time Part-time

Education & Skills

Education: (highest grade completed)
List any education or training (College degrees, vocational, or military certifications, etc.)  
 
Special Skills:  
 

Military Service

Have you served in the U.S. Armed Forces?    Yes No
Did you serve on active duty other than training Yes No
If yes, list ACTIVE DUTY Dates             From
To:

Resources

If needed, do you have:        Tools Valid SD Driver's License
CDL Endorsements

Work History: Describe your most important jobs within the last 10 years, beginning with the most recent.

A) Employer:
City
State
Immediate Supervisor:
Ending Wage:
Job Title:
Start Date: 
End Date:
Job Duties/Responsibilities:
 
 

 

B) Employer:
City
State
Immediate Supervisor:
Ending Wage:
Job Title:
Start Date: 
End Date:
Job Duties/Responsibilities:
 
 

 

C) Employer:
City
State
Immediate Supervisor:
Ending Wage:
Job Title:
Start Date: 
End Date:
Job Duties/Responsibilities:
 
 

 

Summary of other work experinces not listed above  
 

References

Name
Address
City/State/Zip
Phone
   
Name
Address
City/State/Zip
Phone
   
Name
Address
City/State/Zip
Phone

 

I declare the information provided by me in this application is true, correct and complete to the best of my knowledge. I understand that if hired, any falsification, misstatement or omission of fact in connection with my application, whether on this document or not, may result in the immediate termination of my employment. I authorize this employer to verify any and all information provided above. I acknowledge that if hired, I will be an at-will employee. I will be subject to dismissal or discipline without notice or cause, at the discretion of the employer. I also understand that this means I am free to quit my employment at any time, for any reason, without notice. I understand that no representative of the company, other than the executive director, has the authority to change the terms of the at-will relationship and that any such change can occur only in a written employment contract.

I agree to the above statement.  

This application is valid for sixty days from the application date unless renewed in person or in writing.

Our policy is to provide equal employment opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, ancestry, physical or mental disability, or veteran status.