First Name: M.I.: Last Name: Mailing Address: Apt./Unit #: City: State: Zip: Social Security Number - - Birth Date: Telephone #: Address:

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1 Employment Application Date: First Name: M.I.: Last Name: Mailing Address: Apt./Unit #: City: State: Zip: Social Security Number - - Birth Date: Telephone #: Address: How did you hear about this job? Were you referred by an employee? Date available for work: Salary required: per Education High School Phone: Years completed? Did you graduate? Degree Type: College Phone: Dates Attended: Did you graduate? Degree Type: Major: Phone: Dates Attended: Did you graduate? Degree Type: Major: Other Phone: Dates Attended: Did you graduate? Degree Type: Major: Special Courses (Please list any additional training you may have received, including military training, apprenticeship programs, vocational training, courses or seminars.):

2 Employment History Present or Most Recent Employer Company Name: Employer's Phone #: Job Duties: Reason for leaving: _ Additional Employment History Company Name: Employer's Phone #: Job Duties: Reason for leaving: _ Company Name: Employer's Phone #: Job Duties: Reason for leaving: _

3 Company Name: Employer's Phone #: Job Duties: Reason for leaving: _ Briefly describe your long-term career goals: Professional Licenses/Certifications License/Certification State License Number Date Expires References (Please do not include family members or relatives) Name Current Position and Company Phone Number Have you ever been convicted of a felony criminal offense? If so, please explain: Are you legally eligible for employment in the United States of America? I certify that the information I have provided in this employment application is accurate and has been completed to the best of my knowledge and ability. I understand that any falsification, misrepresentation or omission in my interviews or any other employment record, will be sufficient reason to deny employment and/or may be reason for future dismissal. Signature: Date:

4 Employee Information Sheet Employee Name IDENTIFICATION Last M.I First Home Telephone: Address Other Telephone: I.D. DOB: SSN: Driver s License #: State Issued: Other Identification or Endorsements: IN CASE OF EMERGENCY Emergency Contacts: 1) Name Contact # Relationship Secondary Contact 2) Name Contact # Relationship Secondary Contact Physician: Location and/or Phone #: Insurance Carrier: Policy Number: Driver s License or Photo ID Copy Hire Date: Starting Pay: W4 Allowances: Insurance Types: Notes:

5 Post-Interview Evaluation APPLICANT INFORMATION Name: Title Interviewed for: Date: First Impression Responses to Initial questions Professionalism Understanding of Key knowledge areas Qualification level for the position Related Experience Education or training level Perceived overall Performance capability INTERVIEW NOTES Excellent Good Average Fair Poor APPLICATION / RESUME NOTES FEEDBACK FROM REFERENCES

6 Pre-Employment Checklist Applicant Name: Social Security Number Position/Title: Department Interviewed By: Additional Interview Notes: References Contacted: Name: Date Contacted: Notes: Name: Date Contacted: Notes: Name: Date Contacted: Notes: Background Check Completed and Approved? Education & Experience Verified? Applicable Licenses/Certifications Verified? Drug Screening Completed? Results? Applicant Status: Hired Not Hired Type of Employee: Regular Temporary Position Type: Full Time Part Time Benefits: Yes No Available Start Date: Wage/Salary Requested: Official Start Date: Starting Wage/Salary: Approved by: Date:

7 Pre-Interview Questionnaire APPLICANT INFORMATION Name: Job Title Sought: Date: How did you hear about us? PLEASE ANSWER THE FOLLOWING Why are you interested in joining our organization? What are the two most important things in your view, that our organization does? How can you make a positive difference at our organization? What skills do you possess, professional or outside of work that are special or better than average? What is your success story? What achievements, obstacles overcome, or successful things have happened in your life that you are proud of? THANK YOU FOR TAKING THE TIME TO COMPLETE OUR PRE-INTERVIEW QUESTIONNAIRE Use an additional page if needed, to provide more information than space is allowed for above.