Position(s) applied for Date of application NAME LAST FIRST MIDDLE ADDRESS STREET CITY STATE ZIP CODE TELEPHONE CELL ADDRESS

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1 APPLICATION FOR EMPLOYMENT GREAT LAKES INTER-TRIBAL COUNCIL, INC. GLITC is an equal opportunity employer applying Native American Preference as defined in Title 25, U.S. Code, Section and 47, and fully subscribes to the principles of Equal Employment Opportunity. It is the policy of GLITC to provide employment, compensation and other benefits related to employment based on qualifications of the job applied for, without regard to race, color, religion, national origin, age, sex, veteran status or disability, or any other basis prohibited by federal or state law. As an equal opportunity employer, GLITC intends to comply fully with all federal and state laws and the information requested on this application will not be used for any purpose prohibited by law. Disabled applicants may request any needed accommodation from a representative of the Human Resources Department, PO Box 9, Lac du Flambeau, WI or phone (715) or Position(s) applied for Date of application NAME LAST FIRST MIDDLE Former Name Preferred Name ADDRESS STREET CITY STATE ZIP CODE TELEPHONE CELL ADDRESS Referral Source If you are under 18, and it is required, can you furnish a work permit? YES Have you ever been employed here before? YES If yes, please provide dates and positions Are you a U. S. citizen or do you have an entry permit which allows you to lawfully work in the U.S.? YES (Proof of employment eligibility will be required upon employment) Date available to start / / Salary Requirements Type of employment desired Full-Time Part-Time Temporary If Part-time, what days and hours are you available? Page 1

2 EMPLOYMENT HISTORY Start with your present or most recent employer or experience. Please list all positions held and complete position and duties section. Do NOT indicate see resume, even if you include a resume. Please give accurate and complete information. Are you currently employed? Yes No May we contact your current employer? Yes No 1. Position and responsibilities: What you liked most about the position? What you liked least about the position? Reason for Leaving: 2. Position and responsibilities: Page 2

3 What you liked most about the position? What you liked least about the position? Reason for Leaving: 3. Position and responsibilities: What you liked most about the position? What you liked least about the position? Reason for Leaving: EDUCATION Schools Attended Name(s) & Locations High School Graduate YES/NO DEGREE MAJOR SUBJECT/COURSES MINOR Grade Point Average (GPA) College(s) Page 3

4 College(s) Other Job Related Training or Certifications Military Skills Acquired: REFERENCES List name, address and telephone number of three (3) business/work references that are not related to you and do not live with you. If not applicable, list three school or personal references that are not related to you. and and and Page 4

5 APPLICANT STATEMENT GREAT LAKES INTER-TRIBAL COUNCIL, INC Highway 47 North PO BOX 9 Lac du Flambeau, WI Please read the following statements carefully before you sign your name. I HEREBY CERTIFY that the answers given by me to the above questions and statements are true and correct and hereby authorize you to contact references, past or present employers, persons, schools, law enforcement agencies and any other sources of information which may be relevant to my application for employment. It is understood and agreed that any misrepresentation, false statement, or omissions by me in the Application will be sufficient reason for rejection of my application or for dismissal at any time during my employment, without liability to GLITC, Inc. This includes furnishing a false name or social security number. I have read, understand and agree to the above statement. (Please initial here). I further understand that no representative of GLITC, Inc. has the authority to enter into any agreement for employment for any specified period of time and that GLITC, Inc. is not guaranteeing employment for anyone. No employment contract is created by virtue of my being hired by GLITC, Inc., and, if hired, my employment will be at will and may be terminated at any time without prior notice. I have read, understand and agree to the above statement. (Please initial here). If employed, I agree to abide by all of the work and safety rules of GLITC, Inc. I understand that GLITC, Inc. is committed to maintaining a drug-free workplace. I am aware that GLITC, Inc. may require a drug test as part of the hiring process. Also, if employed, I realize that GLITC may conduct post-accident, reasonable suspicion, periodic and/or random drug and/or alcohol testing of its employees. I have read, understand and agree to the above statement. (Please initial here). I understand that this application will remain on file for 60 days for consideration. After 60 days, if I am still interested in a position with GLITC, Inc., it will be necessary for me to complete a new application form. Signature of Applicant Date Page 5