Employment

Connecting Ties, Inc. Employment Application

Position Applied For:
Telephone Number:		Social Security #:

Name:__________________________________________________________________________
	Last	First	Middle
Address:________________________________________________________________________
	Street	PO Box
_______________________________________________________________________________
City	State	Zip

Are you legally eligible for employment in the U.S.?		Yes	No
I am seeking a permanent position:		Yes	No
I am seeking temporary work until (Date): __________________________________________
If necessary for the job I am able to:

Work (Which shifts)?	___________________________________________________________
Work Overtime?		Yes	No
Provide a valid Alaska Drivers License.		Yes	No

Are you able to perform the essential functions of the position with or without accommodation?		Yes	No

IF NECESSARY FOR THE JOB, ARE YOU OVER: 14 15 16 18 19 21 (please circle one)

I WILL BE ABLE TO REPORT TO WORK ____ DAYS AFTER BEING NOTIFIED THAT I AM HIRED.

EDUCATION School Name / Location	Yrs. Completed	Field of Study	Graduate or Degree
College / University
Business / Technical
Other ( May include grammar school )

MILITARY SERVICE : YES NO	Duty/Specialized Training:

REFERENCES: List two personal references who are not relatives or former supervisors.

Name Address/Telephone Occupation Years Known

EMPLOYMENT: List last employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here, in the summary (following this section), or use an extra sheet of paper if necessary.

Employer Name and Address	Position Title: Duties:		Dates Employed From To

			Salary
	Supervisor’s Name	Telephone	Reason for leaving
Employer Name and Address	Position Title: Duties:		Dates Employed From To

			Salary
	Supervisor’s Name	Telephone	Reason for leaving
Employer Name and Address	Position Title: Duties:		Dates Employed From To

			Salary
	Supervisor’s Name	Telephone	Reason for leaving
Employer Name and Address	Position Title: Duties:		Dates Employed From To

			Salary
	Supervisor’s Name	Telephone	Reason for leaving

Summarize other employment related to this job:

Types of computers, other electronic or mechanical equipment you are qualified to operate or repair:

Typing Speed:

Professional Licenses, Certifications or Registrations:

Additional skills including supervision skills, other languages, or information regarding the career/occupation you wish to bring to the employer’s attention:___________________________________________________________

In case of accident or illness, please contact:
Name:	Daytime Phone:________________________

Address: ______________________________________________		Relationship:

Information for the applicant: As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references.

If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the U.S., have a physical examination and/or drug test, or to sign a conflict of interest agreement and abide by its terms.

I understand and agree to the information shown above:

Signature: _________________________________ Date: ____________________

Equal Employment Opportunity: While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment.

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