SCYR Rehire Staff Application
Applicant Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Driver's License Number
Driver's License State
Driver's License Expiration Date
-
Month
-
Day
Year
Date
Do you have any new education, training, licensure, certification, experience, talents, skills or ideas that might benefit the program?
Can you perform the essential functions of the job for which you have applied, with or without reasonable accomodation?
*
yes
no
Have you ever been accused of harassment of any person including, but not limited to, workplace harassment? (a prior conviction is not an automatic bar to employment)
*
yes
no
Have you ever been convicted of a crime, other than a minor traffic offense? (a prior conviction is not an automatic bar to employment)
*
yes
no
I, the applicant, authorize investigation of all statements contained in this application for employment. I understand that, if employed, I will be an at-will employee (able to be dismissed at any time with or without cause) unless that status is altered by law or a written agreement signed by an authorized Localogy executive. I also understand that false or misleading information given in my application or interview may result in dismissal, regardless of the date of discovery.
*
I agree
Applicant Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
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