2448 Gordon Smith Drive, Mobile, AL 36617
APPLICATION FOR EMPLOYMENT
THIS APPLICATION MUST BE FULLY COMPLETED TO BE CONSIDERED FOR EMPLOYMENT.

Date: Select Date

EMPLOYMENT INFORMATION
AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER AND SERVICE PROVIDER
Position Applied For    Location
Referral Source
Last Name   First Name   Middle Name
Street Address
City   State   Zip   County
Home Phone   Business Phone
Social Security No.
Have You Filed an Application Here Before?   Yes     No   Date: Select Date
Have You Ever Been Employed Here Before?   Yes     No   Date: Select Date
What Days Can You Work? - Check All That Apply:   Sun   Mon   Tue   Wed   Thu   Fri   Sat
Pay Expected?          Are You Available?  Full Time   Part Time  Either
  Will You Work Overtime?  Yes   No          What Hours Can You Work?
  Are You on Layoff - Subject to Recall?  Yes  No       Date: Select Date
Do Any of Your Relatives Work for this Agency?   Yes     No  
If Yes, List Name(s)
 
Have You Ever Been Convicted of a Crime?   Yes     No  
If Yes, Explain
 
A conviction record may not necessarily be a bar to employment.
Are You a Veteran of the U.S. Military Services?   Yes     No  
 


Community or Relevant Volunteer Activities
 


EMPLOYMENT HISTORY
(Begin with Present or Most Recent Employer and Complete in Full)
Company Name
Phone
May We Contact?
  Yes     No
Full Address
From
Select Date
To
Select Date
Immediate Supervisor
Supervisor's Job Title
Starting Pay
Ending Pay
Type of Business
Starting Position
Ending Position
Reason for Leaving

Company Name
Phone
May We Contact?
  Yes     No
Full Address
From
Select Date
To
Select Date
Immediate Supervisor
Supervisor's Job Title
Starting Pay
Ending Pay
Type of Business
Starting Position
Ending Position
Reason for Leaving

Company Name
Phone
May We Contact?
  Yes     No
Full Address
From
Select Date
To
Select Date
Immediate Supervisor
Supervisor's Job Title
Starting Pay
Ending Pay
Type of Business
Starting Position
Ending Position
Reason for Leaving

Please Explain Any Gaps in Your Employment History
 
 
EDUCATION

School
Name and Location
Courses
Studied
No. of
Years
Attended
Did You
Graduate?
Degree /
Diploma

College
Yes No

College
Yes No

High School
Yes No

Other
Yes No


SKILLS

Skills List:
(highlight option then click arrows)
NOTE: This list is used in job matching
so be sure to list ALL applicable skills.
Available Skills:   Applicant Skills:
Add To List
Remove from List

Summarize Special Skills and / or Qualifications Acquired Through Employment and / or Education or Other Experience
 


REFERENCES
LIST THREE PERSONS NOT RELATED TO YOU WHOM YOU HAVE KNOWN FOR AT LEAST ONE YEAR WHO HAVE
KNOWLEDGE OF YOUR WORK EXPERIENCE AND / OR YOUR ABILITY TO PERFORM THE JOB FOR WHICH YOU ARE APPLYING.

1. Name
Phone
Relationship to You (Supv., Co-Worker, etc.)
Years Known
2. Name
Phone
Relationship to You (Supv., Co-Worker, etc.)
Years Known
3. Name
Phone
Relationship to You (Supv., Co-Worker, etc.)
Years Known

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. Initial Here  

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same to you.

Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, physical or mental handicap, (except where sex or freedom from such handicap is bona fide occupational qualification) or status as a disabled veteran or veteran of the Vietnam era.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time with or without prior notice and without cause. Initial Here  
NOTICE This application will remain active for ninety (90) days.
Any applicant wishing to be considered for employment beyond ninety (90) days must reapply.


 
VOLUNTARY SELF-IDENTIFICATION FORM
(For Affirmative Action Plan Purposes you are requested to voluntarily provide the information requested below.
Failure to respond will in no way affect the application process)
Goodwill Easter Seals of the Gulf Coast is an equal opportunity employer and is subject to certain reporting and affirmative action requirements. The information requested below is used by Goodwill Easter Seals of the Gulf Coast to maintain records required of employers doing business with the federal government. In an effort to comply with such requirement, we invite you to complete this form. Providing this information is strictly voluntary and will not be used as a basis for employment decisions. A refusal to complete this form will not subject you to any adverse treatment. The information provided will be held in the strictest confidence, and will be maintained separately from the application.
  I Do Not Wish to Self-Identify

Section 1:    General Applicant Information
Gender      Male       Female

Section 2:   Please check one of the following Race / Ethnic Categories
  Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
  White - A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
  Black or African American - A person having origins in any of the Black racial groups of Africa.
  Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
  Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent include, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillipine Islands, Thailand and Vietname.
  American Indian or Alaskan Native - A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.
  Two or More Races - All persons who identify with more than one of the above races.