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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