Lewis County Humane Society Application for Employment

Full Name*

First NameLast Name

DOB (must be 16)*

Date

Phone Number*

Area CodePhone Number

E-mail*

myemail@example.com

Present Address (ideally, we need someone within 20 miles of our shelter):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

YesNo

Driver's License Number*

XXX XX XXXX

YesNo

If yes, please explain:

Position Applied For*

Date you can start*

MonthDayYear

YesNo

You've gotten this far, congrats! Please tell us why you are interested in shelter animal care, specifically.*

Please state your previous employers from most recent to least recent.

Employed From

MonthDayYear

-

Employed To

MonthDayYear

Employer Name

Supervisor Name

Salary

Optional

Position

Reason for leaving

Employed From

MonthDayYear

-

Employed To

MonthDayYear

Employer Name

Supervisor Name

Salary

Optional

Position

Reason for leaving

Employed From

MonthDayYear

-

Employed To

MonthDayYear

Employer Name

Supervisor Name

Salary

Optional

Position

Reason for leaving

YesNo

If yes, please explain why:

YesNo

Which branch and what were your dates of service?

YesNo

MisdemeanorFelony

If yes, please explain:

Enter your education history below

Rows	Years From/To	Graduated (Yes/No)	Courses
High School/GED
College
Trade
Special Classes

Any Additional Comments:

Please give the names of 3 people (other than family) whom you have known for at least 1 year.

First Reference

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

How do you know this person?*

Years Known*

Second Reference

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

How do you know this person?*

Years Known*

Third Reference

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

How do you know this person?*

Years Known*

Electronic Signature*

First NameLast Name

Application Completed*

MonthDayYearHourMinutesAM/PM Option

An Equal Opportunity Employer

GENERAL AGREEMENT I understand that all offers of employment are conditioned on receipt of satisfactory responses to reference requests and provision of satisfactory proof of an applicant’s identity and legal authority to work in the United States. In consideration of my employment, I agree to conform to the rules and standards of The Lewis County Humane Society, as amended from time to time at the employer’s discretion.

AUTHORIZATION TO CHECK REFERENCES I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the information checked unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom the shelter may contact, to provide any and all information concerning my previous employment and any other pertinent information that they may have. I understand that any misinterpretation, falsification, or omission of material information on this application may result in my failure to receive an offer, or if I am hired, in my dismissal from employment.

I agree

Job Application Form