Employment ApplicationPosition Applying for:(Required)Employee InformationName(Required) First Middle Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you able to perform the essential functions of the position with or without accommodations?(Required) Yes NoIf necessary for the job, are you able to work overtime?(Required) Yes NoIf necessary for the job, are you older than:(Required) 14 15 16 18 19 21Are you legally eligible for employment in the U.S.?(Required) Yes NoAre you seeking a permanent position?(Required) Yes NoWhat shifts are you able to work?(Required) Any Day Night Swing Rotating Split GraveyardI will be able to report to work _____ days after being notified I am hired.(Required)Employment HistoryList most recent employment first. Include summer or temporary jobs.Employer Information(Required)CompanyAddressSupervisor Information(Required)NamePhonePosition Title(Required)Pay/Salary(Required)Duties/Skills(Required)Employment Dates(Required)Start DateEnd DateReason for Leaving:(Required)Employer Information(Required)CompanyAddressSupervisor Information(Required)NamePhonePosition Title(Required)Pay/Salary(Required)Duties/Skills(Required)Employment Dates(Required)Start DateEnd DateReason for Leaving:(Required)Summarize other employment related to this job:ReferencesReference 1(Required)NameAddressPhoneOccupationYears KnownReference 2(Required)NameAddressPhoneOccupationYears KnownContactIn case of accident or illness, please contact:(Required)NamePhoneAddressRelationshipInformation to the ApplicantConsent(Required)As part of-our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references. If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms. I understand and agree to the information shown above.Signature(Required)Date(Required) MM slash DD slash YYYY Equal Employment Opportunity: While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment. Developed at employer request by the Alaska Department of Labor & Workforce Development, Employment Security Division.
