PO Box 256
Madison, SD 57042
Phone: (605)256-3644
APPLICATION FOR EMPLOYMENT
INSTRUCTIONS: All job applicants must complete the following form before being employed. Please print in ink or type all answers. Photocopies are acceptable. You are welcome to attach a resume.
Applicant Information
Full Name: /Date:
Last
/First
/M.I.
Address:Street Address
/Apartment/Unit #
City
/State
/ZIP Code
Phone: /Last 4 Soc. Sec. No.:
/Desired Salary:
/ $Position Applied for:
Are you at least age 16 ? / YES / NO /
Are you a citizen of the United States? / YES / NO /
If no, are you authorized to work in the U.S.?
/ YES / NODo you have a valid driver’s license? / YES / NO /
If yes, license State:
/ Number:Have you ever been convicted of a felony? / YES / NO
If yes, explain:
EDUCATION/TRAINING
Do you have a high school diploma or GED?
/ YES / NOHigh School: /
Address:
From: /To:
/Did you graduate?
/ YES / NO /Diploma::
College: /Address:
From: /To:
/Did you graduate?
/ YES / NO /Degree:
Other: /Address:
From: /To:
/Did you graduate?
/ YES / NO /Degree:
Please list any other training that may be applicable to your skills and abilities as a job applicant.Please list business technology you are proficient in such as a cash register, tablets, and computers. Include the operating systems such as Mac, PC, Android, and software used.
Please list your experience with power tools, vehicles, trucks, heavy equipment or other that might be valuable in this job.
WORK HISTORY
Company: /Phone:
Address: /Supervisor:
Job Title: /Starting Salary:
/ $ /Ending Salary:
/ $Responsibilities:
From: /
To:
/Reason for Leaving:
May we contact your previous supervisor for a reference? / YES / NOCompany: /
Phone:
Address: /Supervisor:
Job Title: /Starting Salary:
/ $ /Ending Salary:
/ $Responsibilities:
From: /
To:
/Reason for Leaving:
May we contact your previous supervisor for a reference? / YES / NOCompany: /
Phone:
Address: /Supervisor:
Job Title: /Starting Salary:
/ $ /Ending Salary:
/ $Responsibilities:
From: /
To:
/Reason for Leaving:
May we contact your previous supervisor for a reference? / YES / NOReferences
Professional references other than listed above.
Full Name: /Relationship:
Company: /Phone:
Address:Full Name: /
Relationship:
Company: /Phone:
Address:Full Name: /
Relationship:
Company: /Phone:
Address:Military Service
Branch: /From:
/To:
Rank at Discharge: /Type of Discharge:
If other than honorable, explain:Authorization for Release of Information and Disclaimer
As part of Prairie Village employment process, we may be checking your background relative to job and personal references, criminal record, and social services record. We must have your authorization in order to do this.
The undersigned hereby authorizes any state department of social services, any police department, and Prairie Village, to obtain and /or release any and all information regarding the social services, work, credit, DOT mandated drug/alcohol testing if applicable, or criminal history of the undersigned applicant for consideration for employment by Prairie Village.
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature: /Date:
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