Employment Application

^* denotes required field

Personal

Last Name ^*

First Name ^*

Middle Name ^*

Address ^*

Address 2

City^*

State ^*

Zip ^*

Phone Number ^*

Social Security Number ^*

Date of Birth ^*

21 or older? ^*

Yes

Employment Desired

Position Desired ^*

Date you can start ^*

Desired Salary ^* $

Are you employed now? ^*

Yes

If yes, may we contact present employer?

Yes

May we contact past employers? ^*

Yes

Applied to this company before? ^*

Yes

If yes, when?

Referred by?

Education

Education	School Name	Location	Years Attended	Graduate?	Subject / Major
Grammar School
High School
High School Equivalency
College
Trade School

General

Subjects of Special Study or Research Work :

Special Skills :

Activities (Civic, Athletic, Etc) :

U.S. Military or Naval Service? ^*

Yes

If yes, rank?

Present Membership in National Guard or Reserves? ^*

Yes

Convicted of any violation of the law other than minor traffic violations? ^*

Yes

If yes, explain :

Do you possess a valid drivers license? ^*

Yes

Former Employers

List below last 3 employers, most recent employer first!

Start Date	End Date	Employer Name	Address	Phone Number	Position	Reason for leaving

Which of these jobs did you like best?

What did you like most about this job?

References

Give the names of three persons not related to you, with telephone numbers where they can reached during our regular buisness hours of 8:00am - 3:30pm, Monday - Friday.

Name	Address	Phone	Business / Position	Years Known

In case of emergency

Please list 2 emergency contacts :

Name	Address	Phone

^* I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time. As an applicant for a position with Garrett County Lighthouse, Inc., I have been asked to furnish information for use in reviewing my background and qualifications. In this connection, I hereby authorize Garrett County Lighthouse, Inc. to investigate my past work history, character, education, driving record, military, and police records to ascertain any and all information which may be pertinent to my employment qualifications. I release any individual, including records custodians, from all liability for damages that may result to me on account of compliance or any attempts to comply with this authorization. This release is binding. Now and in the future, on my heirs, assigns, associates, and personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

I agree ^*