UNITED MIGRANT OPPORTUNITY SERVICES, INC. 2701 S. Chase Avenue P.O. Box 04129 Milwaukee, WI 53204 (414) 389-6000 APPLICATION FOR EMPLOYMENT Personal Information Position/s: Location: Full Name: Last First M.I. Present Address: Street Address Apartment/Unit # City State Zip Code Home Phone #: Mobile/Alt. Phone #: E-mail Address: Permanent Address: (if different from above) Street Address Apartment/Unit # City State Zip Code Home Phone #: Mobile/Alt. Phone #: Social Security Number or Government ID: Do you have a car? Yes No What language do you speak? Write?
Emergency Contact Information Full Name: Last First M.I. Present Address: Street Address Apartment/Unit # City State Zip Code Primary Phone #: Mobile/Alt. Phone #: Relationship: Other Information Do you have any relatives that work for UMOS or that are Council/Board members? Yes No If yes, Who and where? What awards, honors, or scholarships have been received? In what extracurricular activities do you participate? What are your special interests, skills, or hobbies?
Education Attended Diploma Name Location From To Y/N Credit Major Grade School High School College/University Graduate Studies Special Training Military Service Branch of Service: Dates: Highest Rank Held: Awards of Citations Received: Present Status: Active Inactive Stand By Job Information (List the names of the most recent employer first) Title: Supervisor: Name of Company: Department: Work Location: Work Phone #: Mobile/Alt. #: Start Dates: End Dates: Last Annual Salary: Duties and Responsibilities: Reason for leaving?
Job Information (continued) Title: Supervisor: Name of Company: Department: Work Location: Work Phone #: Mobile/Alt. #: Start Dates: End Dates: Last Annual Salary: Duties and Responsibilities: Reason for leaving? Title: Supervisor: Name of Company: Department: Work Location: Work Phone #: Mobile/Alt. #: Start Dates: End Dates: Last Annual Salary: Duties and Responsibilities: Reason for leaving? May we contact your present employer (if any)? Yes No
References (Write the name of the persons that are not relatives) Name Address Phone # Occupation How did you find out about this position opening? Why are you interested in this position? I hereby certify that all statements made herein and attached hereto are true to the best of my knowledge and beliefs, and I know that any falsehood or misrepresentation later disclosed will be sufficient grounds for loss or employment. Applicant s Signature Date
Date: Position title applying for: THIS SECTION IS SOLELY USED FOR EQUAL EMPLOYMENT AND AFFIRMATIVE ACTION (EEO/AA) CONTRACT COMPLIANCE INFORMATIONS PURPOSES. THIS SHEET IS NOT SEEN BY HIRING SUPERVISOR! ****CHECK ONLY ONE BOX PER SECTION**** MALE FEMALE ANY TYPE OF DISABILITY (DO NOT GIVE DETAILS) YES WHITE BLACK HISPANIC NO (Not of Hispanic origin All person having origins in any of the original people of Europe, North Africa, or the Middle East) (Not of Hispanic origin All person having origins in any of the Black racial groups of Africa) (Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race) ASIAN OR PACIFIC ISLANDER (All persons having origins in any of the original people of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.) Race/ethnic designations as used by the EEOC do not denote scientific definitions of Anthropological origins. For the purposes of this report, an individual may be included in the group to which he/she appears to belong, identifies with, or is regarded in the community as belonging. However, no person should remain in more than once race/ ethnic group. Definitions are as defined in U.S. Department of Commerce, Office of Federal Statistical Policy, and Standards Directive No. 15, the definitions also Appear in the EEO Instruction Booklet. AMERICAN INDIAN OR ALASKAN NATIVE (All persons having origins in any of the original people of North America, and who maintain cultural identification through tribal affiliation or community recognition.)