Employment Application

APPLICATION FOR EMPLOYMENT

The Psychological Center
www.tpc1.org

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability,
marital or veteran status, sexual orientation, or any other legally protected status.

PLEASE PRINT
Please fill this application as completely as possible

Date of application

Position(s) applying for

How did you learn about us?

Friend Employment Agency	Walk-In Relative	Advertisement Other
If Advertisement or Other please fill in below

PERSONAL INFORMATION

Last Name	First Name	Middle
Address	City	State	Zip

Phone	Email	Social Security Number

Are you at least 18 years of age?

Yes No

Have you ever been employed with us before?

Yes No

If yes, give dates: to

Are you currently employed?

Yes No

Are you currently on “lay-off” status and subject to recall?

Yes No

May we contact your present employer?

Yes No

Are you legally eligible to work in the United States?
Proof of citizenship or immigration status will be required upon employment.

Yes No

Do you have a reliable means of transportation to and from work?

Yes No

Names of relatives employed by us:

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SALARY/SCHEDULE EXPECTATIONS

Date available to start work: Earnings expected $ per hour

What type of employment are you seeking? Full Time Part Time Temp/Seasonal

*Can you work a flexible schedule, including evenings and weekends when needed? Yes No

Please indicate the schedule you are able to work without conflict:

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
-	-	-	-	-	-	-

List the days or hours that you are not able to work:

EDUCATION AND SKILL INFORMATION

	Name and Address of Institution	Diploma / Degree / Certificate	Type of Diploma Degree / Certificate	Major Course of Study
High School
Vocational / Technical
College / University
Apprenticeship or Other

Special Training, Languages, or Skills that would enhance your qualifications:

Technical Skills ( please list the programs you have used, speed or skills you have acquired )

Computer Software

Clerical/Typing Speed

Office Equipment

Military Service

Have you ever served in the United States Armed Forces? Yes No

If so, what Branch? Dates: to

Final Rank:

Special Training:

OTHER INFORMATION

Have you ever been convicted of a felony or misdemeanor? Yes No
Conviction will not necessarily disqualify an applicant from employment.

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EMPLOYMENT HISTORY

How many employers have you worked for in the past 5 years?

Have you ever been involuntarily terminated from an employer? Yes No

If yes, please explain all occurrences

WORK HISTORY

List your current or most recent employer first. Include military service and/or any periods of self-employment. Accuracy of dates, address and telephone numbers is essential.

Dates: Month & Year Required	Company Name, Address & Telephone Number	Position & Summary of Work Performed
From To Hourly Rate

Reason for leaving:
Supervisor: May we contact: Yes No

Dates: Month & Year Required	Company Name, Address & Telephone Number	Position & Summary of Work Performed
From To Hourly Rate

Reason for leaving:
Supervisor: May we contact: Yes No

Dates: Month & Year Required	Company Name, Address & Telephone Number	Position & Summary of Work Performed
From To Hourly Rate

Reason for leaving:
Supervisor: May we contact: Yes No

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Note to Applicants:
DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? Please ask for a description of the activities involved in such a job or occupation. Yes No

PERSONAL REFERENCES

Please give the names of three ( non-family ) references from your professional or academic life.

Name:

Phone:

Company:

Relationship:

Name:

Phone:

Company:

Relationship:

Name:

Phone:

Company:

Relationship:

APPLICANT'S STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signature

Date

The Psychological Center is an Equal Opportunity Employer Thank You for Applying.

EEO Survey (Optional)

Although the following information is not mandatory, it is requested to aid the Psychological Center in its commitment to Equal Employment Opportunity and Affirmative Action. Refusal to answer will not result in adverse treatment of any applicant. The information you give on this page is used to comply with federal guidelines for monitoring equal employment opportunity efforts.

POSITION TITLE FOR WHICH YOU ARE APPLYING:

SEX:

Male

Female

DATE OF BIRTH:

RACE (check only one):

	WHITE (Non-Hispanic)		BLACK (Non-Hispanic)
	HISPANIC		ASIAN or PACIFIC ISLANDER
	NATIVE AMERICAN		OTHER (specify below):

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FOR PERSONNEL DEPARTMENT USE ONLY

Position Applied for is open Yes No

Position considered for

Interviewed Yes No Interviewed By:

Employed Yes No Date of Employment:

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