Employee Application

Date

Name (Last, First, MI)
*

Street Address
*

City, State, Zip
*

Home Phone
*

Work Phone

Facsimile number

Email
*

Social Security Number
*

Drivers License #, State, Expiration date
*

Position Applying For
*

How did you hear about this position?

Date Available for Work
*

Desired rate of pay & full time/part time
*

Highschool Diploma or GED equivalent?

YES

NO

Undergrad or College Degree?

YES

NO

If yes, what course of study?

List any seminars, classes or other education not listed above which may help qualify you for this position

Previous Employer (1)
*

Start Date / End Date of Employment
*

Essential job functions of final position
*

Employment Address

City, State, Zip
*

Employment phone #
*

Previous Employment job position
*

Starting Salary and Ending Salary
*

Name of Supervisor
*

Email Address of supervisor

Reason(s) for leaving
*

What value did you add to this company or its customers?
*

Previous Employer (2)
*

Start Date / End Date of Employment

Essential job functions of final position

Employment Address

City, State, Zip

Employment phone #

Previous Employment job position

Starting Salary and Ending Salary

Name of Supervisor

Email Address of supervisor

Reason(s) for leaving

What value did you add to this company or its customers?

Additional Information: List any professional, trade, business or civic activities and offices held. You may exclude membership that would reveal gender, race, religion, national origin, ancestry, age, disability or any other protected status.

List any languages other than English that you can speak, read or write that could be of benefit to the position applied for:

Identify formal job training that relates to this position:

Identify what skills or certification you possess related to this position:

If you are hired, what value would you add to our company?:

What rate of pay per hour will you be willing to start at to allow North Shreve to see your abilities.

If you are hired on a 30 days trial period with pay adjusted at the end of the 30 days according to value to North Shreve:

Have you ever been employed with this company before?
*

Yes

No

If yes, when?

Do you have any friends or relatives employed by this company?
*

Yes

No

If Yes, please provide their names and relationship to you:

Are you currently employed?
*

Yes

No

May we contact your employer?
*

Yes

No

Are you currently on “lay off” status and subject to recall?
*

Yes

No

If you are under 18 years of age, can you provide proof of your eligibility to work?
*

Yes

No

If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.?
*

Yes

No

Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accommodation?
*

Yes

No

If hired, are there any accommodations the company would need to provide so that you can perform all those essential functions and duties of the position being applied for?
*

Yes

No

If yes, please explain:

If driving is a requirement of the position applied for, have you in the last 7 years been convicted of Driving Under the Influence “(DUI)”
*

Yes

No

N/A

If hired, do you have a reliable means of transportation to and from work?
*

Yes

No

If hired, would you be able to travel or work overtime as needed?
*

Yes

No

If yes, please explain:

Have you ever been convicted of a felony?

Yes

No Record

If so, when?

Within the last five years have you been convicted of or released from incarceration for a misdemeanor, which was not a first offense for drunkenness, simple assault, speeding, a minor traffic violation, an affray or disturbing the peace?

Yes

No Record

If applying from the state of MA

(A criminal conviction will not necessarily be a bar to employment. To help us evaluate your application, please describe the nature of the crime and your subsequent rehabilitation.)

If yes, and applying from the state of MA

Reference # 1: name
*

Only persons not related to you who have knowledge of your work performance within the last 5 years

Reference # 1: occupation
*

Reference # 1: company name
*

Reference # 1: address

Reference # 1: telephone
*

Reference # 1: relationship & years acquainted
*

Reference # 2: name
*

Reference # 2: occupation
*

Reference # 2: company name
*

Reference # 2: address

Reference # 2: telephone
*

Reference # 2: relationship and years acquainted
*

Reference # 3: name
*

Reference # 3: occupation
*

Reference # 3: company name
*

Reference # 3: address

Reference # 3: telephone
*

Reference # 3: email

Reference # 3: relationship and years acquainted
*

Additional space provided to expand on any points or questions asked previously in this application

APPLY WITH NORTH SHREVE