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Position applied for:

Business Manager

Name:

Address:

Telephone Number:

Email Address

Referral Source:

How did you hear about us?

Have you ever been employed here before?

If yes, give dates and positions:

Dates available for work:

What is your desired salary?

Type of employment desired:

Full-Time
Part-Time
Temporary
Seasonal
Educational Co-Op

Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)?

Yes
No
Need more information about the job's "essential functions" to respond

This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Have you ever pleaded "guilty" or "no contest" to, or been convicted of a crime?

If yes, please provide date(s) and details:

Relevant Previous Employer #1 Name/Address/Phone Number:

Starting job title / Ending job title:

Immediate Supervisor and Title (for most recent position held):

Why did you leave?:

Summarize the type of work performed and job responsibilities:

Dates employed (Begin/End):

Compensation (Ending):

May we contact for reference?:

Yes
No
Later

Relevant Previous Employer #2 Name/Address/Phone Number:

Starting job title / Ending job title:

Why did you leave?:

Summarize the type of work performed and job responsibilities:

Dates employed (Begin/End):

Compensation (Ending):

May we contact for reference?:

Yes
No
Later

Relevant Previous Employer #3 Name/Address/Phone Number:

Starting job title / Ending job title:

Why did you leave?:

Summarize the type of work performed and job responsibilities:

Dates employed (Begin/End):

Compensation (Ending):

May we contact for reference?:

Yes
No
Later

Summarize any special training, skills, licenses and/or certifications.

Computer Skills:

Word Processing
Spreadsheet
Presentation
Email
Electronic Health Record
Financial Software (i.e. Quickbooks)

Undergraduate School:

Degree:

Date Completed:

Graduate School:

Degree:

Date Completed:

Application for Employment

Equal access to program, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of Hazel Pittman Center.

Application for Employment