ECD EMPLOYMENT APPLICATION Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Present AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHow Long at Present Address?PhoneSocial Security NumberPrior Address InfoPrior AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHow Long at Prior AddressEmployment InfoAre you eligible to work in the United States? Proof of eligibility will be required before you can be employed)Please select one...YesNoThird ChoiceChoice 4Are you at least 18 years old?Please select one...YesNoWhat date are you available for employment?If applied here before, please provide Location Name, When:If no, do you have a work permit?Please select one...YesNoHave you ever applied here before?Please select one...YesNoAre you presently on layoff or leave of absence from any other company?Please select one...YesNoDo you have any agreements with another employer that might affect your employment here? Please select one...YesNoIf yes, please explain:Your employer will not discriminate against any employee or applicant for employment because of age (as defined by applicable law), religion, sex, race, color, national origin, or because of handicap, veteran status. Answers to application questions will be utilized for applicable job-related information only.AVAILABILITY TO WORK SHEETPlease indicate the times you are available to work below:SundayThursdayMondayFridayTuesdaySaturdayWednesday*Please note: This is an AVAILABILITY SHEET, not a REQUEST SHEET.Activities that may conflict with the information provided above:Are you currently attending school?Please select one...YesNoIf yes, when do you expect your schedule to change again?Thank you for your cooperation.EMPLOYMENT DATAPlease provide past employment record as completely as possible - starting with latest employer (including military service):Employer 1 Name, Address & PhoneDates Employed (MO/YR):Supervisor Name:Capacity:Please select one...Full-timePart-timeSeasonalNature of Work:Salary/Monthly Earnings:Reason for Leaving:Employer 2 Name, Address & PhoneDates Employed (MO/YR):Supervisor Name:Capacity:Please select one...Full-timePart-timeSeasonalNature of Work:Salary/Monthly Earnings:Reason for Leaving:Employer 3 Name, Address & PhoneDates Employed (MO/YR):Supervisor Name:Capacity:Please select one...Full-timePart-timeSeasonalNature of Work:Salary/Monthly Earnings:Reason for Leaving:Employer 4 Name, Address & PhoneDates Employed (MO/YR):Supervisor Name:Capacity:Please select one...Full-timePart-timeSeasonalNature of Work:Salary/Monthly Earnings:Reason for Leaving:Employer 5 Name, Address & PhoneDates Employed (MO/YR):Supervisor Name:Capacity:Please select one...Full-timePart-timeSeasonalNature of Work:Salary/Monthly Earnings:Reason for Leaving:EDUCATION INFOElementary School Name, City, StateLast Elementary Grade CompletedPlease select one...12345678High School Name, City, StateCollege 1 Name, City, StateCollege 1 Avg. GradeLast HS Grade CompletedPlease select one...9101112Did you graduate College 1?Please select one...YesNoCollege 1 Major(s):Did you graduate?Please select one...YesNoCollege 1 Degree?Please select one...YesNoCollege 2 Name, City, State (if applicable)College 2 Avg. GradeDid you graduate College 2?Please select one...YesNoCollege 2 Major(s):College 2 Degree?Please select one...YesNoPlease list other job-related schooling, licenses, certifications, etc. Include Institution mae and expiration dates if applicable.REFERENCESList at least two (2) responsible adults who have knowledge of your work ethic, experience, and ability (do not include relatives, former or present employers, or fellow employees).Reference 1 Name:Reference 1 Occupation:Reference 1 Address:Ref. 1 Relationship to You:Reference 1 Phone:Reference 2 Name:Reference 2 Occupation:Reference 2 Address:Ref. 2 Relationship to You:Reference 2 Phone:Reference 3 Name:Reference 3 Occupation:Reference 3 Address:Ref. 3 Relationship to You:Reference 3 Phone:WORK PREFERENCESAnswer only the questions which for which you are applying:What type of employment do you want?Please select one...Full-timePart-timeSeasonalFor what type of position are you applying for?Are you willing to travel?Please select one...YesNoAre you willing to relocate?Please select one...YesNoMinimum Salary Requirement:What shifts do you prefer?Please select one...1st2nd3rdIf yes to travel, what percent of the time?Past work experience you feel is most applicable to this job:As an applicant for employment, I understand the following:This application will remain on active file for sixty (60) days. If I am hired within this period, this form will be transferred to my individual personnel file.If I am not hired within sixty (60) days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a position after that time.Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for subsequent discipline up to and including my dismissal from employment if discovered at a later date.After an offer of employment has been extended, I may be required to submit to a physical examination. This may include a drug screen, in order to determine my physical ability to perform my job duties with or without accommodation.My employment may be contingent upon the result of this examination and drug screen. If the results of the physical examination indicate that I cannot perform the job for which an offer has been extended and/or if the drug screen results are positive for substance abuse, this will be grounds for disqualifying me or terminating my offer of employment.If my application for employment is accepted, the effective date of employment shall be the time I actually begin to work. If I am employed, I agree to comply with and be bound to the safety and health rules and regulations, and the standards of conduct of my employer.My employment is not guaranteed for any term, and my employment may be terminated by my employer or myself at any time and for any reason. No management official is authorized to make any oral assurance or promise of continued employment.All information (including information on any accompanying resume) is subject to verification.I authorize you to contact and I authorize any present or former employer, education institution, law enforcement agency, financial institution, or other persons having personal knowledge about me to furnish any and all information in their possession regarding me, in connection with any decision concerning my employment. Further, E hereby release from liability and hold harmless all persons and corporations supplying this information. A photocopy of this authorization is as valid as the original.Signature Clear Signature DateCustom Captcha * = Submit
