Equal access to programs, services, and employment is available to all persons. Those Applicants who require accommodation to the application and/or interview should contact Human Resources.

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General Information [ Part 1 ]

First Name:

Last Name :

Address 1 :

Address 2 :

City/State :
Zip Code :

Phone :

Email :
Social Security # :
Who referred
you to ETSec :
What position(s) are you applying for :
Date available
for employment :
General Information [ Part 2 ]
1. May we contact you at your present job?
 
  If "Yes", at what number?
  Best time to call? until
2. If you are under the age of 18, can you furnish a work permit?
  Yes No
3. Are you legally eligible for employment in this country?
  Yes No
  Proof of U.S. Citizenship or Immigration status will be required upon employment.
4. Are you willing to relocate as part of your job assignment?
  Yes No
5. Have you ever been convicted of a crime or offense within the past 10 years which has not been exounged, anulled or sealed by the court, or are you currently under criminal indictment?
  Yes No
  If "Yes", please explain.
(Such a conviction may be relevant if it is job related, but this does not necessarily preclude you from employment.)
Travel
1. Are you willing to travel extensively as part of your job assignment?
  Yes No
2. Do you have a valid drivers license for the state in which you reside?
  Yes No
  If "Yes", what is your license number?
3. Are your driving privileges suspended or revoked in any state?
  Yes No
4. Are you willing to use your car for work?
  Yes No
Military Service
1. Have you served in the U.S. Military?
  Yes No
  If "Yes", in what branch?
  Dates of Service? in
  What is your present classification?
Employment History
 

List your last four (4) employers, assignments or volunteer activities, starting with the most recent. Explain any gaps in employment in the comments section below

Current Employer
Current Employer :
Your Job Title :
Employer Address :
Employer Phone# :
Starting Salary :
Current Salary :
Immediate Supervisor :
Dates Employed : until
Summarize the nature
of the work performed
and job responsibilities :
Reason for Leaving :
May we contact this
employer for a reference : 		Yes No
 
Employer #2
Previous Employer #2 :
Your Job Title :
Previous Employer Address :
Employer Phone# :
Starting Salary :
Ending Salary :
Immediate Supervisor :
Dates Employed: until
Summarize the nature
of the work performed
and job responsibilities:
Reason for Leaving:
May we contact this
employer for a reference: 		Yes No
 
Employer #3
Previous Employer #3
Your Job Title:
Employer Address:
Employer Phone#:
Starting Salary:
Ending Salary:
Immediate Supervisor:
Dates Employed: until
Summarize the nature
of the work performed
and job responsibilities:
Reason for Leaving:
May we contact this
employer for a reference: 		Yes No
 
Employer #4
Previous Employer #4:
Your Job Title:
Employer Address:
Employer Phone#:
Starting Salary:
Ending Salary:
Immediate Supervisor:
Dates Employed: until
Summarize the nature
of the work performed
and job responsibilities:
Reason for Leaving:
May we contact this
employer for a reference: 		Yes No
 
Comments
Include explanation of any gaps in employment
Skills and Qualifications
  Summarize any special training, skills, licenses, certificates and/or characteristics of yourself that may qualify you as being able to perform job-related functions for the position for which you are applying.
 
Education
 
High School
School Name:
Location :
Course of Study :
Years Completed :
Did you graduate? Yes No
Degree / Diploma :
 
Business / Trade / Technical
School Name:
Location :
Course of Study :
Years Completed :
Did you graduate? Yes No
Degree / Diploma :
 
College
School Name:
Location :
Course of Study :
Years Completed :
Did you graduate? Yes No
Degree / Diploma :
 
Graduate
School Name:
Location :
Course of Study :
Years Completed :
Did you graduate? Yes No
Degree / Diploma :
 
Memberships
List Professional or Civic Organization you participate in:
References
   
 

Reference 1

Name :
Address :

Phone :

Title / Relationship :
Years Known :
May we contact? Yes No
 

Reference 2

Name :
Address :

Phone :

Title / Relationship :
Years Known :
May we contact? Yes No
 

Reference 3
Name :
Address :

Phone :

Title / Relationship :
Years Known :
May we contact? Yes No
 

Reference 4
Name :
Address :

Phone :

Title / Relationship :
Years Known :
May we contact? Yes No
  IMPORTANT: Please be sure that you have indicated any references you do not want us to contact at this time.
  Additional Comments
Please provide any additional information that may assist us in evaluating your qualifications in terms of opportunities within our organization. Where applicable, please include bibliography of scientific papers and publications, list patents, descriptions of thesis work, etc. Give specific details of your experience, interests and special skills. List any experiences or other qualifications that are relevant to the position for which you are applying.
 
 

Is your present employer aware that you are considering a change in employment?
  Yes No
Affirmative Action Voluntary Information
  (COMPLETION OF INFORMATION BELOW IS VOLUNTARY)

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability, veteran status or any other legally protected status.

In an effort to comply with Federal and State Regulations pertaining to Equal Employment, we ask that you complete this applicant data survey. Your cooperation is appreciated.

Please be advised that this survey is not a part of your official application for employment. It is considered confidential information that will not be used in any hiring decision and will be kept separate from your application.
 
Referral Source
Employee Advertisement - Source
Gov't. Employment Agency Relative
Private Employment Agency School
Website Other
Name of Person who referred you (if applicable):
Applicant Information
Male   Female
Please check one of the following Equal Employment Opportunity Identification Groups:
White   Hispanic
Black (not of Hispanic origin)   Native American / Alaskan Native
Asian / Pacific Islander      
To Vietnam Era Veterans, Disabled Veterans and Individuals with physical or mental disabilities; If you wish to be identified, please check if any of the following are applicable:
Vietnam era Veteran (served between 1964-1975)
Disabled Veteran
Individual with a disability
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