Name:
Street Address:
City State Zip:
Email:
Age-Over 18:
Home Phone:
Cell Phone:
Business Phone:
Type of employment/position desired:
Wage Expected:
Date Available:
How did you learn of this opening?
Are you eligible to work in the United States?
Check all that apply:
Were you ever employed by our Agency?
Dates Employed?
Positions?
EDUCATION:
High School:
Course or Major:
Grade (Completed):
Degree:
College:
Course or Major:
Grade (Completed):
Degree:
Business, Trade, Apprentice, Correspondence or Military
Course or Major:
Grade (Completed):
Degree:
Are you pursuing a course of study now?
If YES, enter subject and name & location of institution?
EQUIPMENT:
What business machines do you operate?
Average Typing Speed (wpm):
Average Shorthand Speed (wpm):
MILITARY:
Were you in the military or naval forces of the United States between:
Dec 7, 1941 and Dec 31, 1946, both dates inclusive, or, June 25, 1950 and Jan 31, 1955, both dates inclusive
or, Aug 5, 1964 and May 7, 1975, both dates inclusive or, Aug 2, 1990 to present?
Dates Served:
REFERENCES:
List Three Persons (include current or former employers or supervisors)
Name and Position:
Address:
Phone:
Name and Position:
Address:
Phone:
Name and Position:
Address:
Phone:
EMPLOYMENT:
List all employment for past 10 years, including military service and self-employment
Account for all periods of unemployment
Employer (present or most recent)
Address:
Job Title:
Base Wage/Salary:
From (mo/yr):
To (mo/yr):
Supervisor's Name:
Phone:
Describe major job duties:
Full-time?
If no, number of hours worked?
Reason for Leaving:
If presently employed, may we contact your employer for references?
May we contact you at your place of employment?
If yes, your Phone No:
Employer:
Address:
Job Title:
Base Wage/Salary:
From (mo/yr):
To (mo/yr):
Supervisor's Name:
Phone:
Describe major job duties:
Full-time?
If no, number of hours worked?
Reason for Leaving:
Employer:
Address:
Job Title:
Base Wage/Salary:
From (mo/yr):
To (mo/yr):
Supervisor's Name:
Phone:
Describe major job duties:
Full-time?
If no, number of hours worked?
Reason for Leaving:
Employer:
Address:
Job Title:
Base Wage/Salary:
From (mo/yr):
To (mo/yr):
Supervisor's Name:
Phone:
Describe major job duties:
Full-time?
If no, number of hours worked?
Reason for Leaving:
Additional employment history may be emailed to Human Resources at Kresewehr@gwaea.org.
MISCELLANEOUS
Additional Information/Remarks
Have you ever been found guilty of any crime?
If Yes, give date, charge, place, and court below.
Include convictions by General Court Martial while in Military Service. You may omit (1) Traffic Violations for which you paid a fine of $100 or less, and
(2) any offense committed before your 21st birthday which was finally adjudicated in a Juvenile Court or under a Youth Offender Law.
Date:
Charge:
Place:
Court:
AGREEMENT
I understand that:
misrepresentation or omission of facts called for on this application is cause for dismissal.
I may be assigned to positions other than that for which I initially made application
and that my location of work and/or work hours may be changed.
if employed by the Agency, in consideration for such employment, I shall become familiar with
and comply with policies, procedures, and safety practices of the Agency as they exist.
employment is at the will of the Agency.
I authorize:
investigation of all statements contained in this application.
persons, schools, current employer (if applicable) and previous employers and organizations named in
this application (and accompanying resume, if any) to provide this Agency with any relevent information that
may be required to arrive at an employment decision.
A typed name shall constitute a signature.
Applicant's Signature:
Date:
OPTIONAL QUESTIONNAIRE
The Grant Wood Area Education Agency assured Equal Employment Opportunity in all its policies
regarding recruiting, hiring, promotions, and transfers, compensation and other benefits,
training, and layoff and recall practices. Our Agency believes that special measures and
extraordinary effort are required to prevent discrimination and eliminate it within the
organization. We pledge ourselves to a determined and sustained effort in support of this belief.
The Agency must also comply with requirements of reporting affirmative action to city, state,
and federal governments. Thus the reason for the optional questionnaire, we need your assistance
to insure our reports are accurate.
The information contained thereon will be classified as strictly confidential.
Should you have any questions, please don't hesitate to call the Human Resources Office.
REMEMBER, completion of this form is optional! None of the information
that you submit will appear on any application information or be used outside of the
Human Resources Office.
OPTIONAL CONFIDENTIAL QUESTIONNAIRE
Birthdate:
Sex:
Minority Code:
Disability:
