Application for Employment

Please complete this form to the best of your ability.

Last Name

First

Middle

Social Security Number

Present Address

City

State

Zip

Telephone

Permanent Address

City

State

Zip

Telephone

Position Applying For

Salary Desired

How were you referred to this facility?

Are you applying for: Full Time Part Time Permanent Temporary

Relatives or friends employed in this facility? Yes No Department:

Date available for work:

Have you ever been employed by this facility? (When?)

Are you 18 years old or younger? Yes No

Would you consider any shift? Yes No

Weekends/Holidays Yes No

Rotating Shifts Yes No

On Call Yes No

Are you prevented from lawful employment because of your visa or immigration status? Yes No

Please indicate visa type or other immigration status if applicable.

Shift Preference 1st 2nd 3rd

Were you ever convicted of a felony? Yes No

If yes, explain:

Were you ever sanctioned for a violation of a compliance issue? Yes No

If yes, explain:

Education

High School

Name and Address

Course of Study

Check last year completed 1 2 3 4

Did you graduate? Yes No

Diploma or degree

College

Name and Address

Course of Study

Check last year completed 1 2 3 4

Did you graduate? Yes No

Diploma or degree

College

Name and Address

Course of Study

Check last year completed 1 2 3 4

Did you graduate? Yes No

Diploma or degree

Other: Business College, Other Special Cources (Include Special Military Training, Post Graduate, and Nursing)

Area of specialization for major interest

Typing: Approx. WPM:

Shorthand: Approx. WPM:

List health care, business, or industrial equipment operated:

Professional Licenses and/or Certifications

Are you currently: Registered Licensed Certified

Eligible For: Registration Licensure Certification

Type

State Issued

Date

No.

Type

State Issued

Date

No.

Type

State Issued

Date

No.

Language Skills (where related to position sought)

Language

Speak Fair Good Fluent

Read Fair Good Fluent

Write Fair Good Fluent

Language

Speak Fair Good Fluent

Read Fair Good Fluent

Write Fair Good Fluent

Please list name, address, and phone number of previous employers with most recent employer first.

Job Title:

From:

To:

Immediate Supervisor

Last Salary, Hour, Month, or Year

Employer Name

Address & Phone:

Duties:

Reason for Leaving:

Job Title:

From:

To:

Immediate Supervisor

Last Salary, Hour, Month, or Year

Employer Name

Address & Phone:

Duties:

Reason for Leaving:

Job Title:

From:

To:

Immediate Supervisor

Last Salary, Hour, Month, or Year

Employer Name

Address & Phone:

Duties:

Reason for Leaving:

Job Title:

From:

To:

Immediate Supervisor

Last Salary, Hour, Month, or Year

Employer Name

Address & Phone:

Duties:

Reason for Leaving:

State if you do not want us to contact any of the above listed former employers and the reason you do not want each contacted.

Can we run a detailed employment check, including but not limited to a check with your previous employers? Yes No

Did you serve in the U.S. Armed Services? Yes No

What branch

Have you volunteered your time or services? Yes No

Where?

Briefly describe duties and skills acquired through volunteer or military services (include dates):

List at least 3 references who are not relatives or employers:

Name and Relationship

Title

Company Name & Address

Telephone

Name and Relationship

Title

Company Name & Address

Telephone

Name and Relationship

Title

Company Name & Address

Telephone

Name and Relationship

Title

Company Name & Address

Telephone

Name and Relationship

Title

Company Name & Address

Telephone

Make any comments you feel are pertinent to your application.

Release

I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registar/Placement Office of all educational institutions attended to release any official copy of my transcript and if available, faculty appraisals. I agree.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, national origin, handicap, age or sex. Any person who believes he or she has been discriminated against in this program should write to: Administrator, Food & Nutrition Service, 3101 Park Center Drive, Alexandria, VA 22302.