TYPE or PRINT in INK

Please complete the application by typing or clearly printing in dark ink. 

JOB APPLIED FOR

SOCIAL SECURITY NUMBER:

    -              - 

DRIVER’S LICENSE NUMBER:

STATE OF ISSUE:

NAME AND ADDRESS

NAME (LAST, FIRST, M.I.):

HOME TELEPHONE (include area code):

MAILING ADDRESS:

WORK TELEPHONE (Provide only one including area code):

CITY

STATE

ZIP CODE:

OTHER (include area code):

EMAIL ADDRESS:

q PAGER

                q CELL PHONE

q

q PRESENT  EMPLOYER     q LAST EMPLOYER  (Check one):

May We Contact?

CITY AND STATE:

q  Yes    q No

WORK SCHEDULE AVAILABILITY

Check Only One:

Check Only One:

 Date You Can Report For Work:

q PERMANENT

q  SEASONAL              q EITHER

q FULL TIME            q FULL OR PART TIME

q PART TIME          q INTERMITTENT                        q  ANY

 EDUCATION / TRAINING HISTORY

List colleges, military, trade, business or other schools attended.

                  Do you have a high school diploma or a GED certificate?   (Check one)                o YES    o  NO

Name and Location

Of

School, College, or University

Course of Study

(List Major)

Credits Earned

Did You

Graduate?

(Yes / No)

Degree or Certificate Received

A

B

C

LICENSE / REGISTRATION / CERTIFICATE

List any required professional license, registration, certificate, Oregon Commercial Driver’s License (CDL), etc.

Description

State

Number

Expiration

SPECIALIZED SKILLS AND KNOWLEDGE

List skills or knowledge that show your ability to perform the job for which you are applying (such as typing speed,

computer languages or software programs, foreign languages, etc.).  Attach additional pages as needed.

W O R K     H I S T O R Y

JOB NUMBER 1  (current or most recent position)

NAME OF EMPLOYER

EMPLOYER’S ADDRESS and PHONE NUMBER

KIND OF BUSINESS

SUPERVISOR’S NAME and PHONE NUMBER

YOUR JOB TITLE

SUPERVISION / LEADWORK CHECK AREAS YOU WERE RESPONSIBLE FOR:

q  Assigning and Reviewing work             q  Handling Disciplinary problems

q  Rating Work Performance                       q  Responding to Grievances

q  Hiring or Recommending Hiring               q  Not Responsible for Any of Above

If you checked any of these boxes, list the number of employees and their job titles: 

FROM (MONTH - YEAR)

TO (MONTH - YEAR)

TOTAL TIME IN CURRENT

OR LAST POSITION:

HOURS WORKED PER WEEK (Average)

DUTIES (List all duties you performed. No credit will be given if this section is not completed.):

Reason for leaving this position:  

JOB NUMBER 2

NAME OF EMPLOYER

EMPLOYER’S ADDRESS and PHONE NUMBER

KIND OF BUSINESS

SUPERVISOR’S NAME and PHONE NUMBER

YOUR JOB TITLE

SUPERVISION / LEADWORK CHECK AREAS YOU WERE RESPONSIBLE FOR:

q  Assigning and Reviewing work             q  Handling Disciplinary problems

q  Rating Work Performance                       q  Responding to Grievances

q  Hiring or Recommending Hiring               q  Not Responsible for Any of Above

If you checked any of these boxes, list the number of employees and their job titles:

FROM (MONTH - YEAR)

TO (MONTH - YEAR)

TOTAL TIME IN POSITION:

HOURS WORKED PER WEEK (Average)

DUTIES (List all duties you performed. No credit will be given if this section is not completed.):

Reason for leaving this position:  

JOB NUMBER 3

NAME OF EMPLOYER

EMPLOYER’S ADDRESS and PHONE NUMBER

KIND OF BUSINESS

SUPERVISOR’S NAME and PHONE NUMBER

YOUR JOB TITLE

q  Assigning and Reviewing work             q  Handling Disciplinary problems

q  Rating Work Performance                       q  Responding to Grievances

q  Hiring or Recommending Hiring               q  Not Responsible for Any of Above

If you checked any of these boxes, list the number of employees and their job titles:

FROM (MONTH - YEAR)

TO (MONTH - YEAR)

TOTAL TIME IN POSITION:

HOURS WORKED PER WEEK (Average)

DUTIES (List all duties you performed. No credit will be given if this section is not completed.):

Reason for leaving this position:  

CERTIFICATION AND SIGNATURE

I understand that any verbal or written statement that is false, fraudulent or misleading that is contained in this application or attached materials, or made in the course of any related employment process, whether made by me or by others at my request, will result in rejection of my application, denial of employment, or dismissal from service if discovered after employment, and under some circumstances, may result in prosecution for a crime.

w        I certify that all statements contained herein are true and complete whether made by me or others at my request.

w        I understand that if hired, I must prove that I am legally authorized to work in the United States.

w        I authorize The Animal Hospital on Mt. Lookout Square to check employment references and verify education information provided on this employment application and as disclosed in the interview process.

w        I authorize The Animal Hospital on Mt. Lookout Square to check my driving record if the position for which I am applying requires driving.

w        I authorize The Animal Hospital on Mt. Lookout Square to run a credit history check and/or criminal history background check as a condition of employment.

w        I release The Animal Hospital on Mt. Lookout Square and all providers of information from any liability as a result of furnishing and receiving any information related to the State of Ohio’s hiring process.

SIGNATURE

DATE: