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First Name: *

Last name: *

Current Address Street 1: *

Current Address Street 2:

Current Address City: *

Current Address State: *

Current Address Zip: *

Permanent Address Street 1:

Permanent Address Street 2:

Permanent Address City:

Permanent Address State:

Permanent Address Zip:

Email Address: *

Phone: *

Alternate Phone:

For what position are you applying?: *

How did you find out about the position?:

What are the most important factors in choosing a job (1=Most Important; 4=Least Important)

Career Opportunities:

Working for something you believe in:

Salary:

Your work environment:

Other:

Educational History

High School:

Location:

Year Graduated:

College:

Location:

Major:

Year Graduated:

Degree:

Employment History

Please note: Please enter n/a for any boxes for which you do not have information.

Job 1

Employer: *

Address: *

Position: *

Supervisor: *

Phone Number: *

Period Employed From: *

Period Employed To: *

Reason for leaving: *

Job 2

Employer:

Address:

Position:

Supervisor:

Phone Number:

Period Employed From:

Period Employed To:

Reason for leaving:

Volunteer Experience

Political, community, or environmentally oriented::

Health Information

The job for which you are applying involves a substantial amount of public contact to present various issues. Do you have any health conditions, requirements, or physical handicaps that would effect your ability to perform this function? If so, please provide details:

Health Information Value:

Criminal Record

Have you ever been convicted of a crime?: *

Yes

If so, please specify for each conviction:

The approximate date::

The jurisdiction (city and state)::

The crime of which you are convicted::

Any further information or explanation you would like to provide concerning the circumstances of your arrest and conviction.:

Professional References (Other than friends and relatives)

Reference 1:

Name:: *

Organization:: *

Position:: *

Phone number:: *

Reference 2:

Name:: *

Organization:: *

Position:: *

Phone number:: *

Certify: *

Yes

I certify the truth and accuracy of all the information in this application, any attachments to the application and any resume I have submitted. I understand that providing false or misleading information in connection with this application is grounds for discharge.

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