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Personal Info
Name
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Street Address
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Armed Forces Americas
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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)
MM slash DD slash YYYY
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer 1: Job Title
Employer 1: Supervisor
Employer 1: Reason for Leaving
Employer 1: Start Date
MM slash DD slash YYYY
Employer 1: Initial Pay Rate
Employer 1: End Date
MM slash DD slash YYYY
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer 2: Job Title
Employer 2: Supervisor
Employer 2: Reason for Leaving
Employer 2: Start Date
MM slash DD slash YYYY
Employer 2: Initial Pay
Employer 2: End Date
MM slash DD slash YYYY
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer 3: Job Title
Employer 3: Supervisor
Employer 3: Reason for Leaving
Employer 3: Start Date
MM slash DD slash YYYY
Employer 3: Initial Pay Rate
Employer 3: End Date
MM slash DD slash YYYY
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer 4: Job Title
Employer 4: Supervisor
Employer 4: Reason for Leaving
Employer 4: Start Date
MM slash DD slash YYYY
Employer 4: Initial Pay Rate
Employer 4: End Date
MM slash DD slash YYYY
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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