Download Application for Employment

Union Mission, Inc.
Application for Employment
Union Mission, Inc. is an equal opportunity employer. In all of our employment practices, including hiring, we are committed to equal
opportunity without regard to race, religion, sex, age, national origin, sexual orientation, citizenship, disability, veteran status, genetic
information or any other basis of discrimination prohibited by local, state, or federal law. No question on this application is used for the
purpose of limiting or excluding any applicant's consideration for employment on such grounds.
PLEASE ANSWER ALL QUESTIONS
Today’s Date
Position Applying for:
Full Time
NAME:
Part Time
Soc. Sec.#:
last
first
middle
ADDRESS:
Number
Street
TELEPHONE NUMBER:
City
State
(home)
Zip Code
(cell)
Please list any other names you’ve used in the last 5 years: ___________________ Personal Email: __________________________
Are you at least 18 years old?
Yes
No
What wage / salary do you expect?
If hired, when could you start work?
Are you eligible to work in the United States?
Yes
No
Name(s) of friends or family working at Union Mission, Inc. (list name and relationship):
Have you ever been employed by Union Mission, Inc.?
Yes
No
If yes, when and where? ________________________
Have you ever been convicted of any crime other than a minor traffic violation?
Yes
No If yes, provide an explanation:
_____________________________________________________________________________________________________________
Have you ever been discharged or asked to resign from a position?
Yes
No
If yes, provide an explanation:
_____________________________________________________________________________________________________________
What is the highest level of school you’ve completed?
High School Graduate Type of diploma: _______________________ School______________________ State________________
College Graduate
Type of degree: _______________________ School______________________ State________________
Masters Degree
Type of degree: _______________________ School______________________ State________________
PhD
Type of degree: _______________________ School______________________ State________________
Describe any other specialized or professional training or licenses.
PRIOR WORK RECORD (Must show the past 10 years. Start with most recent or present employer.)
Employer (name, address, phone)
Employed from (mo/yr)
to (mo/yr)
Pay start
& Pay final
Your position/title
Reason for leaving
1.
2.
______________
3.
_______
List additional employers on a separate sheet of paper. Please explain fully any gaps in your employment history:
May we contact your current employer?
Yes
Has your driver’s license ever been revoked?
No. If No, please explain: _____________________________________________
Yes
No. Driver’s License #:
State Issued:
In Case of emergency or accident, who should be notified?
Name
Phone #(s)
Address
City, State Zip Code
Name
Phone #(s)
Address
City, State Zip Code
Professional References (Do NOT list relatives. We are looking for people you’ve worked with recently.):
Name
Phone #
Occupation
Name
Phone #
Occupation
Name
Phone #
Occupation
The facts set forth in my application for employment are true and complete. I understand that, if employed, false statement(s) or omissions of
information on this application, a resume or other applicant information provided may be considered sufficient reason for dismissal. You are
hereby authorized to make an investigation of my personal history and financial and credit record through any investigative or credit bureaus
or your choice. I understand that if I am considered for hire for The Counseling Center, a FBI Criminal History Record Check may be
performed and that I have the right to challenge the contents of the Criminal History Record Information, should I choose to do so. I
understand that Union Mission is a drug-free workplace, and I agree to submit to drug/alcohol testing as requested and release Union Mission
from any liability associated with drug/alcohol testing. They may use the lab of their choice.
I authorize the use of any information in this application to verify my statements, and I authorize the past employers, all references, and any
other persons to answer all questions concerning my ability, character, reputation, and previous employment record. I release all such
persons from any liability of damages on account of having furnished such information. I understand that employment at this organization is
on an "at will" basis, and includes no guarantee, contract, or promise of employment for any specific length of time. I understand that the 90
day probationary period does not change the at-will employment relationship.
Signature of Applicant
Revised 3/2011
Date