Expression of Interest
PLEASE PRINT
POSITION(S) APPLIED FOR
DATE OF APPLICATION
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
REFERRAL SOURCE
NAME
First Name
Middle Initial
Last Name
ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
TELEPHONE NUMBER
-
Area Code
Phone Number
EMAIL ADDRESS
example@example.com
If necessary, best time to call you at home is
What is your preferred method of contact?
May we contact you at work?
YES
NO
If yes, work number and best time to call.
If you are under 18, can you furnish a work permit?
YES
NO
Have you filed an application here before?
YES
NO
If yes, give date.
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you ever been employed here before?
YES
NO
FROM
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
TO
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you legally eligible for employment in this country?
YES
NO
(Proof of U.S. citizenship or immigration status will be required upon employment.)
Date available for work.
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Desired hourly wage?
Type of employment desired:
Full Time
Part-Time
Weekends
Temporary
Please state acceptable localities (cities and counties):
Are you on a lay-off and subject to recall?
YES
NO
Will you relocate if the job requires it?
YES
NO
YES
NO
When are you available to work?
Days
Evenings
Nights
Weekends
Will you work overtime if required?
YES
NO
Please be advised that if you are applying for a driving position, you will need to undergo a pre-employment physical, pursuant to federal law. If this is not acceptable to you, please check "NO".
YES
NO
Have you ever been bonded?
YES
NO
Have you ever been convicted of, or entered a plea of guilty or no contest to, a criminal or misdemeanor offense that has not been expunged or sealed?
YES
NO
(Please note that a conviction will not automatically exclude you from consideration for employment.)
If Yes, please explain.
Do you have any pending felony or misdemeanor charges?
YES
NO
If Yes, please explain.
AN EQUAL OPPORTUNITY EMPLOYER
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Employment History
List your last three (3) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in the comments section below.
Employment History
Rows
FROM
TO
Column 4
ADDRESS
JOB TITLE
JOB TITLE
IMMEDIATE SUPERVISOR AND TITLE
REASON FOR LEAVING
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE? YES NO LATER
EMPLOYER TELEPHONE ( ) -
EMPLOYER TELEPHONE ( ) -
ADDRESS
JOB TITLE
JOB TITLE
IMMEDIATE SUPERVISOR AND TITLE
REASON FOR LEAVING
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE? YES NO LATER
Comments (including explanation of any gaps in employment):
SKILLS AND QUALIFICATIONS. Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for work with our Company.
AN EQUAL OPPORTUNITY EMPLOYER
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Education Background
A. List least two (2) schools attended starting with last one. B. List number of years completed. C. Indicate degree or diploma earned, if any. D. Grade Point Average or Class Rank. E. Major and minor field of study (if applicable).
Rows
A. SCHOOL
B. NO. YEARS COMPLETED
C. DEGREE DIPLOMA
D. GPA/ CLASS RANK
E. MAJOR
F. MINOR
1
2
3
List any foreign language(s) and check the box that best describes your skill level.
Rows
LANGUAGE
READ AND WRITE
READ AND SPEAK
READ ONLY
SPEAK ONLY
1
2
References
References List name and telephone number of three (3) business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
Rows
NAME
TELEPHONE
YEARS KNOWN
1
2
3
List professional, trade, business, or civic organizations with which you have been associated and that you consider relevant to your ability to do this job. (Exclude memberships which would reveal sex, race, religion, national origin, age, ancestry or other protected status.)
Rows
ORGANIZATION
ORGANIZATION
OFFICES HELD
1
2
3
List special accomplishments, publications, awards. (Exclude membership which would reveal sex, race, religion, national origin, age, ancestry or other protected status.)
List any additional information you would like us to consider.
AN EQUAL OPPORTUNITY EMPLOYER
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ACKNOWLEDGMENTS
I certify that all information provided by me is true, accurate, and complete. I understand that falsification, misrepresentation, or omission of fact on this application or any other accompanying or required documents will be cause for denial of employment or immediate termination of employment, regardless of how or when it is discovered.
I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information, and I also release the employer from all liability that might result from conducting an investigation.
I understand that this application is not a contract, offer, or promise of employment. I understand that I am free to resign at any time and that the Company is free to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary or alter the at-will nature of the employment relationship.
The Company is an equal opportunity employer. It does not discriminate in employment and no question on this application is used for the purpose of limiting or excluding any applicant's consideration for employment on a basis prohibited by local, state, or federal law.
This application is current for only sixty (60) days. At the conclusion of this time, if I have not heard from the Company and still wish to be considered for employment, I will need to complete a new application.
Signature of Applicant
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mid-Cumberland Human Resource Agency is a non-smoking facility in compliance with the Tennessee Non-Smoker Protection Act.
MID CUMBERLAND
Human Resource Agency
P.O. Box 17385
Nashville, TN 37217
(615) 331-6033
Revised 08-2026
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