Career Preparation

Career Preparation

Summer Program 2017

PRINT IN BLACK INK OR TYPE. These instructions must be followed exactly. Fill out application form completely. If questions are not applicable, enter “NA.” Do not leave questions blank. Be sure to sign when completed.

APPLICANT INFORMATION
Last Name: / First Name:
Middle Name: / Maiden Name:
Date of Birth:
Street Address: / Apartment/Unit#
City: / State: / Zip:
Phone: / Email Address:
Social Security Number xxx-xx-
Are you a citizen of the United States?
YES
NO / If no, are you authorized to work in the U.S.?
YES
NO
Have you ever been convicted of a felony or misdemeanor? YES NO
If yes, please explain:
Are you over the age of 18?
YES
NO / Are you registered with the U.S. Selective Service?
YES
NO
EDUCATION
High School:
From: (mm/yyyy) / To: (mm/yyyy) / Address:
City/State: / Did you graduate?
YES
NO / Degree:
College/Technical School:
From: (mm/yyyy) / To: (mm/yyyy) / Address:
City/State: / Did you graduate?
YES
NO / Degree:
Career/coursework:
ACHIEVEMENTS/AWARDS/HONORS/ORGINAZATIONS
Please list any achievements you have received and/or organizations and activities in which you have participated.
DRIVER’S LICENSE/IDENTIFICATION CARD INFORMATION
State: / Number: / Expiration Date: (mm-dd-yyyy)
__ __ - __ __ - ______
MILITARY SERVICES: A copy of report of separation from the Armed Services may be required.
Are you a veteran
YES
NO / If yes, list type of discharge status: / Date of Service
______to ______/ Are you a serving veteran?
YES NO
PREVIOUS EMPLOYMENT PAID OR UNPAID (list your most current job experience first)
Company: / Phone:
Address: / Supervisor:
Job Title:
Unpaid Internship / Starting Salary: $ / Ending Salary: $
Responsibilities:
From: (mm/yyyy) / To: (mm/yyyy) / Reason for Leaving:
Company: / Phone:
Address: / Supervisor:
Job Title:
Unpaid Internship / Starting Salary: $ / Ending Salary: $
Responsibilities:
From: (mm/yyyy) / To: (mm/yyyy) / Reason for Leaving:
Company: / Phone:
Address: / Supervisor:
Job Title:
Unpaid Internship / Starting Salary: $ / Ending Salary: $
Responsibilities:
From: (mm/yyyy) / To: (mm/yyyy) / Reason for Leaving:
REFERENCES List three professional references that have known you for more than one year.
Full Name:
Company: / Relationship:
Address: / Phone:
Email Address:
REFERENCES CONTINUED
Full Name:
Company: / Relationship:
Address: / Phone:
Email Address:
Full Name:
Company: / Relationship:
Address: / Phone:
Email Address:
ADDITIONAL QUESTIONS
What type of work are you looking for?
Part-time Full-time Temporary Seasonal
Do you have any physical limitations for work?
Do you have any hobbies or special skills? (Please list below)
Emergency Contact Information (Name, Address, Phone, Relationship)
AFFIRMATIVE ACTION
Applicants are considered for all positions, and employees are treated, during employment, without regard to race, color, religion, gender, national origin, age marital or veteran status, medical condition or disability.
As an employer/government contractor, we comply with government regulations and affirmative action responsibilities. Solely to help us, complete the Affirmative Action Form. This is completely voluntarily. We appreciate your cooperation. Refusal to provide this information will not subject you to adverse treatment. This data is for periodic government reporting and will be kept in a confidential file separate from the Application for Employment.
Gender: Male Female
Check all that apply:
Hispanic or Latino / Black or African American / Am. Indian/Alaskan Native
Native Hawaiian/Pacific Asian / White / Veteran
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE YOU UNDERSTANDING AND ACCEPTANCE BY SIGNING IN THE SPACE PROVIDED
1.  I certify that all the information provided by me in connection with my application, whether on this document or not, is true and complete, and I understand that any misstatement, falsification, or omission of information may be grounds for refusal to hire or, if hired, termination.
2.  I understand that as a condition of employment, I will be required to provide legal proof of authorization to work in the U.S.
3.  I understand that the State of Texas requires all males who are 18 through 25 and required to register with the Selective Service, to present either proof of registration or exemption from registration upon hire.
4.  I understand that some state agencies will check with the Texas Department of Public Safety, the Federal Bureau of Investigation or other organizations, for any criminal history in accordance with applicable statues.
5.  I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information that might have, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability from any damages which may result from furnishing such information to you.
THIS APPLICATION
MUST BE SIGNED / SIGN HERE: X
Signature of Applicant / Date

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