If you are under 18 years of age, can you provide required proof of your eligibility to work? YesNo
    YesNo
    YesNo
    Do any of your friends or relatives, other than spouse, work here? YesNo
    Are you currently employed? YesNo
    May we contact your previous employer? YesNo
    Are you available to work? Full-TimePart-TimeTemporary
    Full Time Shift Availability:
    Part Time Availability:

    Are you currently on "lay-off" status and subject to recall? YesNo
    Can you travel if a job requires it? YesNo

    Education

    High School

    Undergraduate College

    Graduate Professional

    Other

    Past Employment

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    4.

    Specialized Skills? Microsoft WordExcelPowerPointPublisherAdobe AcrobatChildPlus

    References

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    Affirmative Action Data Record

    Employees are treated during the hiring process and employment without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

    As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Action responsibilities where they apply.

    The purpose for this Data Record is to comply with government recordkeeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Data Records are kept in a Confidential File and are not part of your Application for Employment or personnel file. Please note: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

      Referral Source
      Gender
      Ethnic Origin
      Check if any of the following are applicable