Employment Application

Employment Application

Date

Employee Information

Name

First NameMiddle NameLast Name

Gender

For insurance/compliance

Social Security Number

Birth Date

MonthDayYear

Preferred/Chosen Name

First NameMiddle NameLast Name

Preferred/Chosen Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

E-mail Address

Employment Information

Hire Date

Please leave blank. Your supervisor will fill this in.

Position Applying For

Department

Please leave blank. Your supervisor will fill this in.

Employment Type

Wage/Salary

Please leave blank. Your supervisor will fill this in.

Additional Employee Information

Are you a US Citizen?

If not, what type of VISA do you have?

Type here

What's expiration date for your VISA?

Date

Do you have a valid driver's license?

Driver's License Number

State of Issue

Expiration Date

Date

Have you ever worked for this company?

If yes, explain when and the position worked.

Type Here

Have you ever been convicted of a crime?

If yes, explain the conviction(s), nature of offense(s), State(s) where offenses occurred, and Sentences(s) imposed by the Court.

Type Here

Have you ever been in the Armed Forces?

Are you presently on active duty or a member of the national guard?

Date Entered

Date

Discharge Date

Date

Type Discharge

Education

High School

High School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Diploma Received

Upload a scan or picture of your high school diploma.

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College/University

Trade school applicable

College/University Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Degree/Trade Documentation Received

Degree Major/Trade Specialty

Upload a scan or picture of your degree or trade certification/license.

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Employment History

If you are uploading your resume, you can skip over the question items in this section.

Upload your resume.

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Most Recent Employer Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Supervisor Name

Start Date

Date

End Date

Date

Job Title

List job responsibilities

Previous Employer Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Supervisor Name

Start Date

Date

End Date

Date

Job Title

List job responsibilities

Job Skills & Training

List and describe your skills.

Training or Certifications:

Employment References

Reference 1

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Relationship

Reference 2

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Relationship

Reference 3

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Relationship

Application Form Waiver

Please read carefully.

In exchange for the consideration of my job application with Belafonte TACOLCY Center, Inc., (hereinafter called "Center"), I agree that:

Neither the acceptan of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless fo the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Center practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of the company, or otherwise to channge in any respect the "employee-at-will" relationship between the Center the undersigned, and that relationship cannot be altered except by written instrument signed by the Director of te Board. Both the employed, I understand that the Center may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in staff and/or benefits.

I authorise investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is causef or dismissal at at tiem without any previous notice. I hereby give the Center permission to contact schools, previous employers (unless otherwise indicated), references and others. I further authorize the Center to complete a criminal background check and obtain a copy of my driving record. I hereby release the Center from any liability as a result of such contacts, inquiries, or records in ordr to ascertain my qualifications and fitness for employment.

I also understand the: (1) The Center has a drug and alcohol policy that provides for pre-employment testing as well as a random testing program after my employment; (2) my consent to and compliance with such policy is a condition of my employment; (3) continued employment is based on the successful passing of testing under such policy. I furhter understand that continued employmenet may be based on the successful passing of job-related physical examinations.

I have also authorized by my signature the following Drug Testing Consent For in order that my application can be processed.

I further understand that my employment with the Center shall be probationary for a period of ninety (90) days, and any further that at any time during the probationary period or thereafter, my employment relationship with the Center is terminable "at will" for any reason by either party.

The Center is an Equal Employment Opportunity Employer (EEOE). We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, age or disability. We assure you that your employment with this Center depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

Signature