EmailMe Form - Application for Employment

Position Applying for *

Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Daytime Phone

### - ### - ####

Evening Phone

### - ### - ####

Email *

When will you be available to begin work?

Education Information

Choose Highest Grade Completed

High School

Dates Attended

Graduated?

Yes

No

Third option

College/University

Dates Attended

Graduated?

Yes

Graduate or Professional

Dates Attended

Graduated?

Yes

No

Other Education

Dates Attended

Graduated?

Yes

No

Other Training

Licenses and Certifications (list, giving dates and sources of issuance):

Equal Oppurtunity Information

East Wake Academy policy prohibits discrimination based on race, sex, color, creed, national origin, age or disability. The information below will in no way affect you as an applicant.

Gender

Female

Male

Ethnic Group

DISABILITY:

"Disability means, with respect to an individual: (1) a physical or mental impairment that substantially limits one or more of the major life activities of such individual; (2) a record of such an impairment; or (3) being regarded as having such an impairment" (Americans with Disabilities Act of 1990). Persons without a disability should check item A.
The reporting of a disability is strictly VOLUNTARY. Persons with disabilities who DO NOT WISH to report their disabilities should check item A. Information reported on this form will be kept confidential as required by State law. Public disclosure of this information without your consent would be a violation of G.S.

Other

If M. Other, please explain

Work History

Current or Last Employer:

Name of Company

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Start Date

MM / DD / YYYY

End Date

MM / DD / YYYY

Starting Salary

$ Dollars . Cents

per

Ending Salary

$ Dollars . Cents

per

Reason for Leaving

List major duties in order of their importance in the job

Previous Employer

Name of Company

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Start Date

MM / DD / YYYY

End Date

MM / DD / YYYY

Starting Salary

$ Dollars . Cents

per

Ending Salary

$ Dollars . Cents

per

Reason for Leaving

List major duties in order of their importance in the job

Previous Employer

Name of Company

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Start Date

MM / DD / YYYY

End Date

MM / DD / YYYY

Starting Salary

$ Dollars . Cents

per

Ending Salary

$ Dollars . Cents

per

Reason for Leaving

List major duties in order of their importance in the job

Previous Employer

Name of Company

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Start Date

MM / DD / YYYY

End Date

MM / DD / YYYY

Starting Salary

$ Dollars . Cents

per

Ending Salary

$ Dollars . Cents

per

Reason for Leaving

List major duties in order of their importance in the job

Briefly state what you think makes you qualified to the job for which you are applying:

References

List 2 References other than your former supervisors or family:

Name

First Last

Phone

### - ### - ####

Name

First Last

Phone

### - ### - ####

Have you ever been convicted of a crime?

Yes

No

If yes, please explain

I certify that I have given true, accurate and complete information on this form to the best of my knowledge. In the event confirmation is needed in connection with my work, I authorize educational institutions, associations, registration, and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigation of all statements made in the application and understand that false information or documentation, or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action or dismissal if I am employed, and (or) criminal action. I further understand that dismissal upon employment shall be mandatory if fraudulent disclosures are given to meet position qualifications (Authority: G.S. 126-30, G.S. 14-122.1.)

Signature of Applicant *

Date Time *

MM / DD / YYYY

Attach a Resume

Optional