Senior Center Application for Employment

Fill this in on screen, then print it to sign. Nothing you type is sent anywhere — the form works entirely in your browser, so nothing is saved if you close the page. If you would rather write it out by hand, print the blank pages first. Your Social Security number and your signature are left blank on purpose: write them on the printed copy.

Email address

Date

Last name

First name

Middle initial

Social Security number (write this on the printed copy)

Street number and name

Phone number

City

State

County

Zip code

Position applying for

Hours sought Full-time Part-time

Date available for work

Expected salary

Reason for interest in this position

Special training / skills

References

Please list names of individuals (other than relatives) qualified to comment on your past employment record. If not previously employed, list names of individuals (other than relatives) who can comment on your character and personal qualities.

References
Name	Address	Occupation	Phone

Education

Education
Education	School name and address	Type of major	Did you graduate?	Degree / credits
Elementary
High school
College, university or tech school
Other schools

Military history

Are you a veteran? Yes No

Branch of service

Dates served

Date of honorable discharge

Date of dishonorable discharge

Employment history

Please account for all years. Begin with the most recent.

Employer 1

Years

From / to

Position

Reason for leaving

Organization

Address

Salary

Name and title of immediate supervisor

Phone (with area code)

Employer 2

Years

From / to

Position

Reason for leaving

Organization

Address

Salary

Name and title of immediate supervisor

Phone (with area code)

Employer 3

Years

From / to

Position

Reason for leaving

Organization

Address

Salary

Name and title of immediate supervisor

Phone (with area code)

Additional questions

Do you have any relatives working for this company?

Are you authorized to work in the United States? Yes No

If not, have you filed an application for citizenship?

Are you able to perform the duties of the job (with or without reasonable accommodation) for which you are applying? Yes No

Were you ever removed, for cause, from any previous employment? Yes No

If so, give explanation

Have you ever been convicted of any crime (felony or misdemeanor)? Yes No

I hereby certify that the information presented on this form is true, accurate and complete. Any falsification, misrepresentation or omission will be sufficient cause for disqualification or dismissal. References and personal information, which become a part of this record, are to be regarded as confidential and will not be revealed to me. I understand the Senior Center will conduct an inquiry regarding my background and experience, and I authorize participating persons to verify any and all information contained herein by any means possible. I knowingly and voluntarily release from any and all liability anyone giving information regarding me (whether in my application or not) so long as the information is relevant to the duties for which I have applied.

Date

Signature (sign after printing)

Equal opportunity employer

Sign and date the printed copy, add your Social Security number, then deliver or mail it to the Pickaway County Senior Center, 2105 Chickasaw Drive, P. O. Box 565, Circleville, Ohio 43113.