Application for Employment

Contact Information

• First and last name
• Date of application
• Email address
• Street address, city, state, and ZIP code
• Primary and secondary phone numbers

Employment Eligibility and Availability

• If under 18, ability to furnish a work permit when required
• U.S. citizenship or legal authorization to work in the United States
• Position or positions sought
• Full-time or part-time preference
• Availability for weekdays, weekends, evenings, nights, and overtime
• Available days and hours when seeking part-time work
• Desired wage
• Ability to meet the position’s attendance requirements
• Ability to perform the essential functions of the position, with an explanation if unable
• Previous employment at the facility, including dates
• Relatives or friends employed by the facility
• Family Care Safety Registry status
• Possession of an appropriate valid driver’s or chauffeur’s license when required

Education

High School

• School name
• City and state
• Degree, diploma, or GED

Additional Education

• School name and location
• Course of study
• Years completed
• Degree earned
• Name used in school records, if different from the applicant’s current name

Skills and Qualifications

Summarize any special training, skills, licenses, or certificates that demonstrate the ability to perform job-related functions for the position sought.

Employment History

Provide details for past and current employers, beginning with the most recent. Explain employment gaps in the comments section.

For each employer, provide:

• Employer name, telephone number, and address
• Starting and final job titles
• Immediate supervisor’s name and title
• Reason for leaving
• Permission to contact the employer for a reference
• Dates employed
• Starting and final hourly rate or salary
• Summary of work performed and job responsibilities

Additional Comments

Include any relevant comments and explanations of gaps in employment.

References

List three business or work references who are not related to you. Provide each reference’s name, telephone number, and number of years known.