| PERSONAL INFORMATION |
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| Date: |
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Telephone #: |
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| First Name: |
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Business Phone #: |
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| Last Name: |
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Mobile #: |
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| Street Address: |
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E-mail Address: |
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| City: |
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State:
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Zip:
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| If hired, when can you start? |
| Are you legally eligible for employment in the United States?
Yes
No |
| Social Security #: |
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Drivers License #:
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State:
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| Provide the days and hours that you are available for work: |
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday |
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| EMPLOYMENT EXPERIENCE |
| Please provide an accurate and complete record of your full-time and part-time employment record. Start with your present or most recent employer. Be sure to attach your resume. |
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| Employer: |
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Supervisor's Name: |
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| Start Date: |
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Supervisor's Phone #: |
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| End Date: |
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Starting Salary: |
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| Street Address: |
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Ending Salary: |
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| City: |
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State:
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Zip:
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| Responsibilities: |
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| Reason for Leaving: |
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| May we contact this employer? (If not, state reason):
Yes
No |
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| Employer: |
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Supervisor's Name: |
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| Start Date: |
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Supervisor's Phone #: |
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| End Date: |
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Starting Salary: |
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| Street Address: |
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Ending Salary: |
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| City: |
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State:
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Zip:
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| Responsibilities: |
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| Reason for Leaving: |
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| May we contact this employer? (If not, state reason):
Yes
No |
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| Employer: |
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Supervisor's Name: |
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| Start Date: |
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Supervisor's Phone #: |
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| End Date: |
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Starting Salary: |
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| Street Address: |
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Ending Salary: |
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| City: |
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State:
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Zip:
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| Responsibilities: |
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| Reason for Leaving: |
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| May we contact this employer? (If not, state reason):
Yes
No |
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| REFERENCES |
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| First Name: |
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Home Phone #: |
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| Last Name: |
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Business Phone #: |
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| Street Address: |
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Relationship to you: |
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| City: |
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State:
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Zip:
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| First Name: |
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Home Phone #: |
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| Last Name: |
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Business Phone #: |
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| Street Address: |
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Relationship to you: |
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| City: |
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State:
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Zip:
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| First Name: |
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Home Phone #: |
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| Last Name: |
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Business Phone #: |
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| Street Address: |
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Relationship to you: |
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| City: |
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State:
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Zip:
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| EDUCATION |
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| Name of School: |
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School Location: |
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| Course of Study: |
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# Years Completed: |
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| School Address: |
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Relationship to you: |
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| City: |
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State:
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Zip:
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| Did You Graduate? |
Yes
No |
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| Degree / Diploma Received:
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| Please specify foreign language skills: |
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| TRAINING |
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| Certifying Institution: |
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Date Attended: |
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| Location: |
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Certification Received: |
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Date Received: |
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| Certifying Institution: |
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Date Attended: |
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| Location: |
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Certification Received: |
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Date Received: |
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| Certifying Institution: |
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Date Attended: |
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| Location: |
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Certification Received: |
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Date Received: |
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| REFERRAL SOURCE |
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Computer/Internet Listing
Newspaper Ad
Employee Name:
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| APPLICANTS IN THE STATE OF CALIFORNIA AND MINNESOTA ONLY |
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Please check here to have a copy of your consumer report sent directly to the address listed in the "Personal Information" section of this application. |
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| APPLICANTS IN THE STATE OF MARYLAND ONLY |
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| Under Maryland law, an employer may not require or demand any applicaton for employment or prospective employment or any employ to submit to or take a polygraph, lie detector, or similar test or examination as a condition of employment or continued employment. Any employer who violates this provision is guilty of a misdemeanor and is subject to a fine not to exceed $100.00. |
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| It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. Any employer who violates this law shall be subject to criminal penalties adn civil liability. |
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| AUTHORIZATION |
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| I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to provide any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release Sensitive Sitters from all liability for any damage that may result from utilization of such information. |
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I certify that placing my name below shall serve as my signature of authorization. |
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| Name: |
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Date: |
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