Employment Application

INSTRUCTIONS Complete all portions of this application that are applicable to you and the positions for which you are applying. failure to do so may result in the application being returned to you. Type or print clearly in ink. If you need assistance or accommodation in completing this application, please inform our receptionist or call us at 334-742-2700.
EMPLOYMENT APPLICATION AN EQUAL OPPORTUNITY EMPLOYER Incomplete Applications May Not be Considered	2506 LAMBERT DRIVE OPELIKA, AL 36801 PHONE (334) 742-2700 FAX (334) 742-2729
Full Name First Middle (Maiden) Last
Address
House or Apt No. Street
City State Zip Code
Social Security Number
Driver's License # State
How were you referred to our Center?
Have you ever been employed by our Center?
Have you ever made previous application to our Center?

Title of positions for which you are applying
Full-Time Part-Time Relief
Date available for employment
If there are any hours you are unwilling to work, what are they?
Telephone Numbers: Home ( ) Work ( ) Other ( )
List names of relatives and friends working for this agency

FOR OFFICE USE ONLY

Date

Letter

Reference Check by

Interview for

App #

EDUCATION High School Diploma or GED? [ ]Yes [ ]No (Verification will be required)

If no, circle highest grade completed 1 2 3 4 5 6 7 8 9 10 11 12

Name and location of business, correspondence, or

vocational school attended

FROM

Mo. Yr.

Did you

Graduate?

Area of

Study

Degree

Name and location of Colleges and Universities attended

FROM

Mo. Yr.

Did you

Graduate?

G.P.A.

Maximum

obtainable G.P.A.

Field(s) of Study

Major(s) Minors(s)

Degree

and Date

Graduate/Professional/Medical School

Residency/Internship/Fellowship

List professional certificates or licenses and state where issued

Is your license current and in good standing? Yes No

Educational subjects and/or training related to the duties of the position for which you are applying.

Sem. Hrs.

Qtr. Hrs.

Office/business machines operated

Software packages operated

Professional Memberships

Word processing preference

Typing Speed/WPM (net)

Employment applications are active for six months.

FORM 14-42 (07/01)

Have you ever been disciplined or counseled for harassment, attendance, or failure to follow policies? [ ] Yes [ ] No

Have you ever been involuntarily terminated, or forced to resign from a position (do not include layoffs)? [ ] Yes [ ] No

Have you ever been convicted of a moving vehicle violation (including speeding tickets & accidents) or

had your driver's license suspended or revoked within the past 5 years? [ ] Yes [ ] No

Have you ever been convicted of a crime? [ ] Yes [ ] No

Do you have any pending legal charges? [ ] Yes [ ] No

If you answered "Yes" to any of the above questions, attach an explanation on a separate sheet.

Can you, upon employment, submit verification of your legal right to work in the U.S.? [ ] Yes [ ] No

Are you 18 years of age or older? [ ] Yes [ ] No

If no, do you have a work permit? [ ] Yes [ ] No

WORK HISTORY

Beginning with your PRESENT or most recent employment, list in REVERSE ORDER periods of employment. Each time you changed jobs or your title changed should be listed as a separate period. Describe in detail your specific duties as they relate to the duties of the position for which you are applying. Attach additional sheets if necessary.

1. Current or Last Employer				Your Official Job Title
Address					Type of Business
City State					Telephone ( )
From Mo. Yr.	To Mo. Yr.	If part-time, number of hours per week	Beginning Salary $ per		Ending Salary $ per	May we contact employer? [ ] Yes [ ] No
Name of Supervisor				Reason for Leaving
Describe your Duties
2. Current or Last Employer				Your Official Job Title
Address					Type of Business
City State					Telephone ( )
From Mo. Yr.	To Mo. Yr.	If part-time, number of hours per week	Beginning Salary $ per		Ending Salary $ per	May we contact employer? [ ] Yes [ ] No
Name of Supervisor				Reason for Leaving
Describe your Duties

3. Current or Last Employer				Your Official Job Title
Address					Type of Business
City State					Telephone ( )
From Mo. Yr.	To Mo. Yr.	If part-time, number of hours per week	Beginning Salary $ per		Ending Salary $ per	May we contact employer? [ ] Yes [ ] No
Name of Supervisor				Reason for Leaving
Describe your Duties
4. Current or Last Employer				Your Official Job Title
Address					Type of Business

For Services 24 hours a day: (334) 742-2877 or (800) 815-0630