BASIN, WY 82410 APPLICATION FOR EMPLOYMENT Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or the presence of a non-job-related condition or handicap. (Please Print) Date of Application: Circle Position(s) Applied for: Dispatcher Detention Deputy Clerical Maintenance Housing Control Food Service Referral Source: Advertisement Friend Relative Walk-In Employment Agency Other: Name: Last First Middle Address: Street City State Zip Telephone: Home # Work # Cell # Social Security Number / / Date of Birth: Have you filed an application here before? Yes No If yes, give date: Have you ever been employed here before: Yes No If yes, give date: 2/20/2015 1
Are you employed now? Yes No employer? May we contact your present On what date would you be available to begin work? Are you available to work: Full Time Part-Time Temporary Are you on a lay-off and subject to recall? Yes No Can you travel if the job requires it? Yes No Have you been convicted of a felony? Yes No If yes, please explain: Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes No (Proof of citizenship or immigration status may be required upon employment) Are you a veteran of the U.S. Military Service? Yes No If yes, Branch Indicate what foreign languages you speak, read, and/or write: Speak Read Write Fluently Good Fair List professional, trade, business, or civic activities and offices held: (Exclude those which indicate race, color, religion, sex, or national origin) 2/20/2015 2
BASIN, WY 82410 Give name, address and telephone number of five references who are not related to you and are not previous employers: #1_ #2_ #3_ #4_ #5_ Employment Experience Start with your present or last job. Include military service assignments 2/20/2015 3
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Special Skills and Qualifications Summarize special skills and qualifications acquired from employment or other experience: 2/20/2015 5
EDUCATION Elementary School: Years Attended: High School: Years Attended: Did you graduate: Yes No Year: College/University: Years Attended: Did you graduate: Yes No Year: Degree/Profession: Describe specialized training, apprenticeship, skills and extra-curricular activities: 2/20/2015 6
***READ BEFORE YOU SIGN*** The facts set forth in my application for employment are true and complete and I certify that this application was personally completed by me. I understand that if employed, any false statement on this application may result in my dismissal, or if during hiring process, disqualification. I further understand that this application is not, and is not intended to be, a contract of employment, nor does this application obligate the employer in any way if the employer decides not to employ me. You are hereby authorized to make any investigation of my personal history, financial and credit record through any investigation of credit agencies or bureaus of your choice. In making this application for employment, I authorize an investigative report whereby information is obtained through personal interviews with my neighbors, friends, and others with whom I am acquainted. This inquiry, if made, may include information as to my character, personal characteristics, and mode of living. Signature in full Date Completed 2/20/2015 7