Employment Application

* denotes required field


21 or older? *

Employment Desired


Are you employed now? *

If yes, may we contact present employer?

May we contact past employers? *

Applied to this company before? *


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


U.S. Military or Naval Service? *

Present Membership in National Guard or Reserves? *

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

Do you possess a valid drivers license? *

Former Employers

List below last 3 employers, most recent employer first!

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


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.