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Black River Good Neighbor Services Employment Application
(Please Print)
Full Name: _____________________________________________________________________
Street Address: __________________________________________________________________
City:_________________________________________________State:_______________ Zip Code ____________________
Phone: ______________________________________________ Email: ___________________________________________
Date Available: ______________________________________
Desired Salary: $ ___________________________________
Position Applied for: ______________________________________________________________
Are you a citizen of the United States? YES_____ NO _____
If no, are you authorized to work in the U.S.? YES _____ NO _____
Have you ever worked for this company? YES_____ NO_____ If yes, when? ____________________
Have you ever been convicted of a felony? YES NO
If yes, explain: ____________________________________________________________________________
Education
High School: ______________________________ Address: _____________________________________
From: _____________________To: ____________ Did you graduate? YES ____NO ____
Diploma: _________________________________
College: _________________________________ Address:
From: ____________________ To: _____________ Did you graduate? YES ____ NO ____
Degree: ___________________________________
Other: ____________________________________ Address: _____________________________________
From: ___________________ To:_____________ Did you graduate? YES____ NO____
Degree: __________________________________
References
Please list three references (Not relatives)
Full Name: ______________________________________Relationship: ___________________________
Company: ______________________________________Phone: ________________________________
Address: _______________________________________________________________________________
Full Name: _____________________________________ Relationship: ____________________________
Company: _____________________________________ Phone: _________________________________
Address: _______________________________________________________________________________
Full Name: _____________________________________ Relationship: ____________________________
Company: _____________________________________ Phone: _________________________________
Address: _______________________________________________________________________________
Previous Employment
Company: ______________________________________ Phone: ________________________________
Address: _______________________________________Supervisor: _____________________________
Job Title: ______________________________________ Salary: $ _______________________________
Responsibilities: _________________________________________________________________________
From: ___________________ To: ________________ Reason for Leaving: _________________________
May we contact your previous supervisor for a reference? YES____ NO ____
Company: ______________________________________ Phone: ________________________________
Address: _______________________________________Supervisor: _____________________________
Job Title: ______________________________________ Salary: $ _______________________________
Responsibilities: _________________________________________________________________________
From: ___________________ To: ________________ Reason for Leaving: _________________________
May we contact your previous supervisor for a reference? YES____ NO ____
Company: ______________________________________ Phone: ________________________________
Address: _______________________________________Supervisor: _____________________________
Job Title: ______________________________________ Salary: $ _______________________________
Responsibilities: _________________________________________________________________________
From: ___________________ To: ________________ Reason for Leaving: _________________________
May we contact your previous supervisor for a reference? YES____ NO ____
Military Service
Branch: _______________________ From: ____________ To: ______________
Rank at Discharge: _________________________ Type of Discharge: ____________________________
If other than honorable, explain: ___________________________________________________________
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature: ________________________________________________________ Date: _________________________
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