Employee Substitute Staffing

Job Application

We consider applicant for all positions without regard to race, color, national origin, age, religion, sex, marital status, veteran or military status, disability, or any other legally protected status.

Please print in blue or black ink or type. Please include a resume with your application.

Personal Information:

NAME ______

LAST MIDDLE FIRST

Social Security Number ______

Street Address ______

City, State, Zip ______

Home Number ______Cell Number ______Email______

Are you eligible to work in the United States? ___Yes ___No

Are you a United States Citizen? ____Yes ____No

If you are under age 18, do you have an employment/age certificate? ____Yes ___No

Have you been convicted of or pleaded no contest to a felony in the last five years?

____ Yes ____No If yes, please discuss the nature of the offense ______

Do you speak another language fluently? ___Yes ___No What language?______

Are there any special need arrangements we should make before we assign you to a job site?

______

POSITION/AVAILABILITY:

Positions(s) Applied For:

___Secretarial ___Sales ___Accounting ___Receptionist ____ Special Project/Seasonal

___Data Entry ___House Sitting ____Other—Please explain ______

Days/Hours Available Check the day/list the hours:

Monday ______

Tuesday ______

Wednesday ______

Thursday ______

Friday ______

Saturday ______

Sunday ______

EDUCATION: (Begin with high school)

Name of SchoolDegree/DiplomaGraduation Date Specialization

______

______

______

______

List computer programs in which you are proficient. ___PC _____MAC

List and special certifications or training you have:

EMPLOYMENT HISTORY:

Present or last position:

Employer:______Address: ______

Supervisor: ______Phone:______

Email: ______Position Title:______From: ______To:______

Responsibilities: ______

Salaray:______Reason for leaving: ______

May we contact Your Past/Present Employer? _____Yes ____No

List the last three jobs you have held if the above is less than five years.

Employer Phone Company and Dates Responsibilities

______

______

______

REFERENCES:

Name/Title/Address/Phone

1.

2.

3.

List all your personal skills that would make you an asset to Employee Substitute Staffing.

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature ______Date ______

Return to: Employee Substitute Staffing

145 W. Travis

La Grange, TX78945

CHB Consulting, Inc. doing business as Employee Substitute Staffing is in no way responsible for acts of negligence or tort whether accident or intentional, or any criminal act, by the employed substitute resulting in loss or harm to the employing agency