NEPS - Employment Application

(1) High School

Graduated?

Yes No

(2) Technical School

Graduated?

Yes No

Course of Study

(3) College / University

Graduated?

Yes No

Course of Study

(4) Post-Graduate

Graduated?

Yes No

Course of Study

Please list all previous employment, beginning with the most recent.
Please make sure all fields are filled out completely.

(1) Employer

Phone Number

Please enter a valid phone number.

Start Date

End Date

If this is your current employer, please leave blank

Position Held

Reason for Leaving

Description of Duties

Supervisor's Name & Title

May we contact?

Yes No

(2) Employer

Phone Number

Please enter a valid phone number.

Start Date

End Date

If this is your current employer, please leave blank

Position Held

Reason for Leaving

Description of Duties

Supervisor's Name & Title

May we contact?

Yes No

(3) Employer

Phone Number

Please enter a valid phone number.

Start Date

End Date

If this is your current employer, please leave blank

Position Held

Reason for Leaving

Description of Duties

Supervisor's Name & Title

May we contact?

Yes No

Please select all special skill trainings and/or certifications you have:

First Aid / CPR DDS Medical Administration Certification

Are you experienced in using personal computers and/or tablets? *

Yes No

Please select all software, programs and/or applications you are able to use:

MS Office (Word, Excel, Outlook, Powerpoint, OneNote, Access) Spreadsheets (Excel, Google Sheets) Database Management (MS Access, Oracle, MySQL) Presentations/Slideshows (Powerpoint, Google Slides) Social Media (Facebook, Instagram) Digital Marketing (WIX, JotForm)

What other software, programs and/or applications are you capable of using?

Please list three persons who can speak to your
work experience, skills & experience and/or personal character.

Type of Reference

Employment Professional Academic Personal

Name

First Name Last Name

Years Known

Email Address

example@example.com

Phone Number

Please enter a valid phone number.

Type of Reference

Employment Professional Academic Personal

Name

First Name Last Name

Years Known

Email Address

example@example.com

Phone Number

Please enter a valid phone number.

Type of Reference

Employment Professional Academic Personal

Name

First Name Last Name

Years Known

Email Address

example@example.com

Phone Number

Please enter a valid phone number.

Authorization and Acknowledgements

I affirm that the information I have provided in this application is true to the best of my knowledge, information and belief, and I have not knowingly withheld any information requested. I understand that withholding or misstating any information requested in this application is grounds for rejection of my application, and that providing false or misleading information in this application is grounds for discharge.

I authorize the company to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure.

Signature of Applicant

Clear

Date

	FIRST SHIFT ( Approx. 7:00am to 4:00pm)	SECOND SHIFT ( Approx. 3:00pm to 11:00pm)	THIRD/OVERNIGHT SHIFT ( Approx. 10:00pm to 7:00am)	Not Available
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday