Securing Resources for Consumers Employment Application

3711-C University Drive

Durham, North Carolina 27707

945 West Andrews Avenue

Henderson, NC 27536

All potential inquires are evaluated without regard to race, color, religion, gender, national origin, age, marital status or veteran status, the presence of non-job related handicap or any other legally protected status.

Date of Application

Position Sought

How Did You Learn Of This Position?

Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Desired/Wage Salary

When Are You Available

SSN

Driver's License Number/State

Have you ever been convicted of an offense against the law other than a minor traffic violation? If yes, please explain the circumstances:

High School

City/State

Years Attended

Did You Graduate?

YesNo

Degree Received

Undergraduate School

City/State

Years Attended

Did You Graduate?

YesNo

Degree Received

Graduate School

City/State

Years Attended

Did You Graduate?

YesNo

Degree Received

Vocational School

City/State

Years Attended

Did You Graduate?

YesNo

Degree Received

Other Training, Certifications, Or License Held (I.E. First Aid, CPR, NCI, LPC, LCSW)

Employer

Position Held

City/State

Dates of Employment (From and To)

Starting/Ending Salary

Duties Performed

Reason For Leaving

Employer

Position Held

City/State

Dates of Employment (From and To)

Starting/Ending Salary

Duties Performed

Reason For Leaving

Employer

Position Held

City/State

Dates of Employment (From and To)

Starting/Ending Salary

Duties Performed

Reason For Leaving

List Other Information Pertinent To The Employment You Are Seeking

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Professional or Personal Reference

ProfessionalPersonal

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Professional or Personal Reference

ProfessionalPersonal

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Professional or Personal Reference

ProfessionalPersonal

Have You Ever Been Voluntarily Terminated Or Asked To Resign From Any Position Of Employment? If yes, please explain the circumstances

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at a decision.

This application for employment shall be considered active for a period of time not to exceed forty-five (45) days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the employee may resign at any time and the employer may discharge the employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in
writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview (s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signature

Date

Please Attach Your Resume Here

Securing Resources for Consumers Employment Application

Applicant

Education History

Work Experience 1

Work Experience 2

Work Experience 3

Additional Information

References

Acknowledgement and Authorizations