Job Application

Personal Info

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Position Applying For(Required)

Will you accept part-time (less than 40 hours/week) or on-call work?(Required)

Yes

No

Hourly rate expected(Required)

Date available(Required)

Education

(All education listed will be confirmed with the school(s).)

High School/GED

Name & Location

Course of Study

Graduate?

Yes

No

College/University

Name & Location

Course of Study

Graduate?

Yes

No

Business/Vocational

Name & Location

Course of Study

Graduate?

Yes

No

Graduate/other

Name & Location

Course of Study

Graduate?

Yes

No

Training

Describe any other training (workshops/seminars) you have completed that will qualify you:

List any professional certifications or licenses you have earned:

Employment Experience

Start with your present or last job and go back five (5) years, listing former employers. You may include military service assignments and volunteer activities.

Employer 1

Employer 1: Name

Employer 1: Phone

Employer 1: Address

Street Address Address Line 2 City State ZIP Code

Employer 1: Job Title

Employer 1: Supervisor

Employer 1: Reason for Leaving

Employer 1: Start Date

Employer 1: Initial Pay Rate

Employer 1: End Date

Employer 1: Final Pay Rate

Employer 1: Work Performed / Job Duties:

Employer 2

Employer 2: Name

Employer 2: Phone

Employer 2: Address

Street Address Address Line 2 City State ZIP Code

Employer 2: Job Title

Employer 2: Supervisor

Employer 2: Reason for Leaving

Employer 2: Start Date

Employer 2: Initial Pay

Employer 2: End Date

Employer 2: Final Pay Rate

Employer 2: Work Performed / Job Duties

Employer 3

Employer 3: Name

Employer 3: Phone

Employer 3: Address

Street Address Address Line 2 City State ZIP Code

Employer 3: Job Title

Employer 3: Supervisor

Employer 3: Reason for Leaving

Employer 3: Start Date

Employer 3: Initial Pay Rate

Employer 3: End Date

Employer 3: Final Pay Rate

Employer 3: Work Performed / Job Duties

Employer 4

Employer 4: Name

Employer 4: Phone

Employer 4: Address

Street Address Address Line 2 City State ZIP Code

Employer 4: Job Title

Employer 4: Supervisor

Employer 4: Reason for Leaving

Employer 4: Start Date

Employer 4: Initial Pay Rate

Employer 4: End Date

Employer 4: Final Pay Rate

Employer 4: Work Performed / Job Duties

Professional References

Most recent supervisors or instructors are required. Do not list friends or relatives.

Reference 1: Name

Reference 1: Phone

Reference 1: Street

Reference 1: City

Reference 1: State

Reference 1: Zip

Reference 2: Name

Reference 2: Phone

Reference 2: Street

Reference 2: City

Reference 2: State

Reference 2: Zip

Reference 3: Name

Reference 3: Phone

Reference 3: Street

Reference 3: City

Reference 3: State

Reference 3: Zip

Ability

Can you perform all the essential functions of the position for which you are applying with or without a reasonable accommodation?

Can you perform all the essential functions of the position for which you are applying without a reasonable accommodation?(Required)

Yes

No - Please Explain

If No, Please Explain:

Supplemental Background Information

Have you ever been convicted for neglect or abuse, sexual abuse, or other acts of violence?(Required)

No

Yes

Are you currently being investigated for neglect or abuse of any kind?(Required)

No

Yes

Have you ever been terminated from any job for any reason other than a layoff?(Required)

No

Yes

Please provide dates and explanations if you answered "Yes" to any of the last three questions.

Background Information Release

Have you ever been convicted of any criminal offense, either misdemeanor or felony?(Required)

No

Yes

If yes, please explain:

Do you have any tickets on your driving record?(Required)

No

Yes

If yes, please explain:

I give A.T. Klemens my permission to conduct a background investigation. I hereby authorize any law enforcement agency and/or child protection agency to release any records they have regarding me to A.T. Klemens. I understand that my potential employment is contingent upon these reports. A photocopy of this form is as valid as the original.(Required)

Yes

I authorize A.T. Klemens to obtain a copy of my motor vehicle record to evaluate my insurability or for other permissable uses related to my application. If I am hired for employment by A.T. Klemens, I hereby authorize A.T. Klemens to procure these records on a periodic basis or as deemed necessary to evaluate my continuing insurability.(Required)

Yes

Agreement

I hereby authorize A.T. Klemens to inquire as to my record with any or all of my former employers with no liability arising therefrom. I hereby certify that all information above is true and complete to the best of my knowledge. I am aware that falsification or misrepresentation of required information is grounds for dismissal or disqualification from employment with A.T. Klemens(Required)

Yes

I understand that if I am employed by A.T. Klemens it may change wages, benefits, and conditions at any time and that there is no guarantee of permanent employment.(Required)

Yes

Comments

Please list any additional comments or special qualifications you would like to be considered:

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Personal Info

Education

High School/GED

College/University

Business/Vocational

Graduate/other

Training

Employment Experience

Employer 1

Employer 2

Employer 3

Employer 4

Professional References

Ability

Supplemental Background Information

Background Information Release

Agreement

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