General Information
  Position Sought
  First Name: Last Name:
Email:
  Present Address:
Street: City:
State: Zip:
 
  Previous Address:
Street: City:
State: Zip:
  Current Telephone:
  If you are presently employed may we contact your employer? Yes No
  Are you eligible to work in the US? Yes   No
  Salary Expected: Date Available:
  Person to Contact In Case of Emergency
  Name: Address:
  Day Phone: Night Phone:
  Referral Source (e.g., newspaper, school, walk-in, current employee - be specific)
Have you ever applied to or worked at the Center? Yes   No
  Position: Dates:
  Are there any limitations to your work hours? Yes   No
  If yes please explain:
Will you work evenings if necessary? Yes   No
Will you work Saturday/Sunday if necessary? Yes   No
  Upon offer of employment, would you be willing to submit to a national background check? (Convictions will not necessarily exclude you from employment, but will be reviewed in light of circumstances, including date and nature of violation) Yes No
  CHC is a drug-free workplace. Upon offer of employment, would you be willing to submit to a drug screen? Yes No
  Relatives Employed by the Center
  Name: Relationship:
  Education
  High School
  Name of School: City & State:
  Course of Study: Last year completed:
  Diploma/Degree: Grade Avg.
  College
  Name of School: City & State:
  Course of Study: Last year completed:
  Diploma/Degree: Grade Avg.
  Post - Graduate
  Name of School: City & State:
  Course of Study: Last year completed:
  Diploma/Degree: Grade Avg.
  Other
  Name of School: City & State:
  Course of Study: Last year completed:
  Diploma/Degree: Grade Avg.
  Extracurricular activities: (exclude activities relating to race, religion, national origin, gender, age, or disability)
  Leadership Positions Held: (exclude activities relating to race, religion, national origin, gender, age, or disability)
  Military Experience
  Service Branch: Dates:
  Rank at Discharge:
  Skills Acquired:
  Business Experience
  Present or Most Current Employer
  Employer: From: To:
  Street Address: Telephone:
  City: State: Zip Code:
  Wage/Salary: Your Position:
  Reason for Leaving:
  Previous Employer
  Employer: From: To:
  Street Address: Telephone:
  City: State: Zip Code:
  Wage/Salary: Your Position:
  Reason for Leaving:
  Previous Employer
  Employer: From: To:
  Street Address: Telephone:
  City: State: Zip Code:
  Wage/Salary: Your Position:
  Reason for Leaving:
  Previous Employer
  Employer: From: To:
  Street Address: Telephone:
  City: State: Zip Code:
  Wage/Salary: Your Position:
  Reason for Leaving:
  Present or Most Current Employer
  Employer: From: To:
  Street Address: Telephone:
  City: State: Zip Code:
  Wage/Salary: Your Position:
  Reason for Leaving:
  Have you ever been discharged or asked to resign from any position? Yes   No
  If yes please explain:
  Please explain all periods of unemployment:
  Do you have any other job that you would expect to continue if employed here? Yes   No
  If yes please explain:
  Please list any other businesses or companies in which you are involved or have financial interest:  
  Please list any business skills (computer, bilingual, etc.):  
  Personal References
  List four individuals who can discuss your work and job performance.
  Name: Company:
  Phone:    
  Name: Company:
  Phone:    
  Name: Company:
  Phone:    
  Name: Company:
  Phone:    

Acknowledgment - Read Carefully

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