SERRC Employment Application

Contact Information

First Name: *

Middle Name:

Last Name: *

Email Address: *

Contact Phone: *

Work Phone:

Physical Address

Street Address:

City: *

State:

Zip Code:

Mailing Address

Street Address: *

City:

State:

Zip Code: *

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High School

Do you have a high school diploma or GED certificate?:

High School Name:

High School Graduate?:

High School City and State:

College

College Graduate?:

College Name:

College City and State:

College Subjects Studied, Grades Received:

Trade, Business or Correspondence School

Trade School Graduate?:

Trade, Business or Correspondence School Name:

Trade, Business or Correspondence School Address:

Subjects Studied / Degree(s) Received:

Additional Education

Special Study / Research:

Special Interests / Certificates / Experiences:

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Employer Contact

May we contact your present employer?:

May we contact your previous employers?:

Current/Most Recent Employment

Employer:

Position Title:

Reason for Leaving:

Employer Address:

Pay Rate:

Supervisor Name:

Phone:

Past Employer #1

Employer Name:

Position Title:

Reason For Leaving:

Employer Address:

Date Started:

Date Left:

Pay Rate:

Supervisor Name:

Phone:

Past Employer #2

Employer Name:

Position Title:

Reason For Leaving:

Employer Address:

Date Started:

Date Left:

Pay Rate:

Supervisor Name:

Phone:

Past Employer #3

Employer Name:

Position Title:

Reason For Leaving:

Employer Address:

Date Started:

Date Left:

Pay Rate:

Supervisor Name:

Phone:

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Reference 1

Name:

Address:

Contact Phone:

Business Phone:

Relationship:

Reference 2

Name:

Address:

Contact Phone:

Business Phone:

Relationship:

Reference 3

Name:

Address:

Contact Phone:

Business Phone:

Relationship:

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Convictions

Have you ever been convicted of a felony?:

Have you been convicted of a misdemeanor within the past 5 years?:

Are you currently under arrest or indictment for any violation of law?:

If the answer to any of the above is yes, please explain:

Resume Upload

Resume:

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Application Agreement

I hereby certify that all information made on or in connection with this application is true and complete to the best of my knowledge and belief. I understand that any misrepresentation or concealment of material fact will be sufficient ground for rejection of my application or dismissal from employment. I authorize investigation of all statements made in this application, I understand and agree that my employment lasts for no definite period of time and may, regardless of the date of payment of my wages or salary, be terminated at any time without previous notice.

Application Agreement: *

I Agree

I hereby certify that all information made on or in connection with this application is true and complete to the best of my knowledge and belief. I understand that any misrepresentation or concealment of material fact will be sufficient ground for rejection of my application or dismissal from employment. I authorize investigation of all statements made in this application, I understand and agree that my employment lasts for no definite period of time and may, regardless of the date of payment of my wages or salary, be terminated at any time without previous notice.

Authorization for Reference Checks

I hereby authorize my past employers and listed and non-listed references to release information to SERRC regarding my employment, provided the information is used solely to determine my suitability for employment with SERRC. I release SERRC from liability for relying in good faith on the information so provided. This release of information covers my employment record in general, information relating to my character, general reputation, and personal characteristics as those subjects bear on my suitability for employment, in addition to other information relating to my educational and work experience.

Reference Check: *

I Agree

I hereby authorize my past employers and listed and non-listed references to release information to SERRC regarding my employment, provided the information is used solely to determine my suitability for employment with SERRC. I release SERRC from liability for relying in good faith on the information so provided. This release of information covers my employment record in general, information relating to my character, general reputation, and personal characteristics as those subjects bear on my suitability for employment, in addition to other information relating to my educational and work experience.

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