EMPLOYMENT APPLICATION

EOE of Minorities/Females/Vets/Disability

DOH / # / Div
NAME / NAME(LAST) (FIRST) (MIDDLE) / SOCIAL SECURITY NUMBER
- -
FOMER / OTHER NAME(S) USED / HOME PHONE NUMBER
PRESENT ADDRESS (NUMBER AND STREET (CITY) (STATE) (ZIP CODE) / OTHER CONTACT PHONE NUMBER
PREVIOUS ADDRESS (NUMBER AND STREET (CITY) (STATE) (ZIP CODE) / E-MAIL ADDRESS:
PERSONAL DATA / POSITION DESIRED / WHAT SALARYRANGE DO YOU CONSIDER APPROPRIATE? (blank will void application) / How did you learn about position?
DATE AVAILABLE FOR EMPLOYMENT / APPLYING FOR
FULL TIME PART TIME TEMPORARY OTHER ____
HAVE YOU PREVIOUSLY APPLIED TO IDPL?
NO YESIF YES, WHEN? WHAT POSITION?
TO PERFORM THIS JOB YOU:
WILL NEED A REASONABLE ACCOMMODATION
OR
WILL NOT NEED A REASONABLE ACCOMMODATION / Are you legally authorized to work in the US?
Yes No
Will you now or in the future require sponsorship for employment visa status (e.g. H-1B visa status)?
Yes No
LIST ANY RELATIVES CURRENTLY EMPLOYED BY IDPL
EDUCATION / SCHOOLS / NAMES AND LOCATIONS OF INSTITUTIONS / DATES
FROM TO / GRADUATED
YESNO / DATE GRADUATED / AREAS OF SPECIALIZATION / MAJOR / MINOR
HIGH SCHOOL / /
Contact number to verify attendance
(required)
UNIVERSITY / COLLEGE
PHONE
ADDRESS / /
G.P.A. / ON SCALE OF
Contact number to verify attendance
(required)
UNIVERSITY / COLLEGE
PHONE
ADDRESS / /
G.P.A. / ON SCALE OF
Contact number to verify attendance
(required)
UNIVERSITY / COLLEGE
PHONE
ADDRESS / /
G.P.A. / ON SCALE OF
Contact number to verify attendance
(required)
OTHER COURSES, WORKSHOPS, SEMINARS AND OTHER SPECIALIZED OR ADVANCED TRAINING RECEIVED
MEMBERSHIPS, ACTIVITIES, POSITIONS OF LEADERSHIP (SCHOOL, CIVIC, COMMUNITY, SPECIAL INTEREST GROUPS, EXCLUDING ANY ORGANIZATION, THE NAME OR CHARACTER OF WHICH MAY REVEAL RACE, RELIGION OR NATIONAL ORIGIN OF ITS MEMBERS)
OFFICE MACHINES AND EQUIPMENT OPERATED / TYPING-WPM
EMPLOYMENT DATA
EMPLOYMENT DATA / LIST EMPLOYERS BEGINNING WITH THE MOST RECENT(cells expand as you type)
*(Some employer are subcontracting verification of employment and salary history to a 3rd party, please provide the appropriate number to call to verify this information)
NAME OF EMPLOYER
ADDRESS / SUPERVISORNAME
TITLE / EMPLOYER PHONE NO.
LOCATION EMPLOYED / FULL-TIMEPART-TIME / SUPERVISOR E-MAIL / YOUR TITLE
FROM – MONTH AND YEAR
MM YY / TO - MONTH AND YEAR
MM YY / STARTING SALARY / PRESENT OR FINAL SALARY / NUMBER OF PERSONS SUPERVISED
REASON(S )FOR LEAVING / IF STILL EMPLOYED, MAY WE CONTACT THE PRESENT EMPLOYER?Yes / No
DESCRIBE YOUR PRINCIPAL RESPONSIBILITIES
COMPANY CONTACT TO VERIFY EMPLOYMENT & SALARY HISTORY
*
EMPLOYMENT DATA
NAME OF EMPLOYER
ADDRESS / SUPERVISORNAME
TITLE / EMPLOYER PHONE NO.
LOCATION EMPLOYED / FULL-TIME PART-TIME / SUPERVISOR E-MAIL / YOUR TITLE
FROM – MONTH AND YEAR
MM YY / TO - MONTH AND YEAR
MM YY / STARTING SALARY / PRESENT OR FINAL SALARY / NUMBER OF PERSONS SUPERVISED
REASON(S )FOR LEAVING / IF STILL EMPLOYED, MAY WE CONTACT THE PRESENT EMPLOYER?Yes / No
DESCRIBE YOUR PRINCIPAL RESPONSIBILITIES
COMPANY CONTACT TO VERIFY EMPLOYMENT & SALARY HISTORY
*
EMPLOYMENT DATA
NAME OF EMPLOYER
ADDRESS / SUPERVISORNAME
TITLE / EMPLOYER PHONE NO.
LOCATION EMPLOYED / FULL-TIME PART-TIME / SUPERVISOR E-MAIL / YOUR TITLE
FROM – MONTH AND YEAR
MM YY / TO - MONTH AND YEAR
MM YY / STARTING SALARY / PRESENT OR FINAL SALARY / NUMBER OF PERSONS SUPERVISED
REASON(S )FOR LEAVING / IF STILL EMPLOYED, MAY WE CONTACT THE PRESENT EMPLOYER?Yes / No
DESCRIBE YOUR PRINCIPAL RESPONSIBILITIES
COMPANY CONTACT TO VERIFY EMPLOYMENT & SALARY HISTORY
*
REFERENCES: Please list three professional references of past supervisors: / COMPANY / TITLE / E-MAIL ADDRESS / TELEPHONE
1.
2.
3.
4.
UNEMPLOYMENT / Accounts for all periods of unemployment, other than school, in the last five years.
FROM / TO / STATE RESPONSIBILITIES
MO. / YR. / MO. / YR.
MO. / YR. / MO. / YR.
MO. / YR. / MO. / YR.
US MILITARY DATA / BRANCH OF SERVICES / DATES OF SERVICE From To
TYPE OF SPECIALTY TRAINING / HIGHEST RANK ATTAINED
PRIMARY DUTIES
GENERAL INFROMATION / Use the space below to describe your interest in IDPL and the skills and aptitudes that you feel qualify you for this position.
IMPORTANT
READ THOROUGHLY BEFORE SIGNING
Employment at IDPLis for no definite period and may, regardless of seniority, time and manner of payment of wages and salary,be terminated at any time by IDPLor by any employee, with or without cause, and without any previous notice. Further, no organization manager or representative of IDPL, other than the Chief Executive Officer of IDPL has the authority to enter into an agreement contrary to the foregoing. This lack of guarantee or employment contract also applies to other benefits, working conditions, and privileges of employment at IDPL.
I, as the applicant understand that this application will be given every consideration, but its receipt does not imply that I will be employed.
I agree that references and prior employersmay furnish information requested by IDPLincluding salary history, employment history, degree verification, educational attendance, and performance information,and that such person and organizations are released of such claims resulting from the release of information or records.
I understand that proof of authorization for employment in the United States is a requirement in accordance with the Immigration Reform and Control Act of 1986.
I agree to submit to paper and pencil inventories and/ or aptitude tests if required for the position.
I agree, in consideration of my employment, to conform to all of the rules and regulations IDPL either has or in the future will issue.
I understand that misrepresentations, omissions or false statements on this Application or other supplemental information furnished by me whenever discovered, will be sufficient reason for cancellation of consideration for employment or for separation from IDPL if I have been employed.
NAME
HOME ADDRESS / SSN
SIGNATURE / DATE

ONCE COMPLETED ELECTRONICALLY, PRINT FORM, SIGN AND DATE AND SUBMIT IT ON-LINE WITH THE REST OF YOUR APPLICATION MATERIALS.

THANK YOU FOR YOUR INTEREST IN INSTITUTO DEL PROGRESO LATINO

Last Revised: KAJ01072015