Application for Employment

Bemidji Regional Interdistrict Council

	How Did You Learn About Us?  Advertisement  Friend  Walk-in  Employment Agency  Relative  Other ___________________

Last Name First Name Middle Name
Address Number Street City State Zip Code
Telephone Number(s)	Social Security Number

Have you ever filed an application with us before?	 Yes  No If Yes, give date
Have you ever been employed with us before?	 Yes  No If Yes, give date
Are you currently employed?	 Yes  No
May we contact your present employer?	 Yes  No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status may be required upon employment.	 Yes  No
On what date would you be available for work?	_______________________________
Are you available to work:  Full Time  Part Time	 Temporary
Are you currently on “lay-off” status and subject to recall?	 Yes  No
Can you travel is a job requires it?	 Yes  No
Have you ever been convicted of a felony? Conviction will not necessarily disqualify an application from employment.	 Yes  No
If yes, please explain

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

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Education

	Name & Address of School	Course of Study	Years Completed	Diploma Degree
High School
College
Graduate School
Other (specify)

	Indicate any foreign languages you speak, read and/or write.
SPEAK READ WRITE	FLUENT GOOD FAIR

Describe any specialized training, apprenticeship, skills and extra-curricular activities.

Describe any job-related training received in the United States military.

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Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender national origin, disabilities or other protected status.

Employer: _____________________________________________________________________________________________

Address: ______________________________________________________________________________________________

Telephone Number(s):_____________________________________ Job Title: ____________________________________

Supervisor: ____________________________________________ Reason for Leaving: _____________________________

Dates Employed: From:___________ To: ___________ Hourly Rate/Salary: Starting: ___________ Final: __________

Work Performed: _______________________________________________________________________________________

_______________________________________________________________________________________________________

Employer: _____________________________________________________________________________________________

Address: ______________________________________________________________________________________________

Telephone Number(s):_____________________________________ Job Title: ____________________________________

Supervisor: ____________________________________________ Reason for Leaving: _____________________________

Dates Employed: From:___________ To: ___________ Hourly Rate/Salary: Starting: ___________ Final: __________

Work Performed: _______________________________________________________________________________________

_______________________________________________________________________________________________________

Employer: _____________________________________________________________________________________________

Address: ______________________________________________________________________________________________

Telephone Number(s):_____________________________________ Job Title: ____________________________________

Supervisor: ____________________________________________ Reason for Leaving: _____________________________

Dates Employed: From:___________ To: ___________ Hourly Rate/Salary: Starting: ___________ Final: __________

Work Performed: _______________________________________________________________________________________

_______________________________________________________________________________________________________

Employer: _____________________________________________________________________________________________

Address: ______________________________________________________________________________________________

Telephone Number(s):_____________________________________ Job Title: ____________________________________

Supervisor: ____________________________________________ Reason for Leaving: _____________________________

Dates Employed: From:___________ To: ___________ Hourly Rate/Salary: Starting: ___________ Final: __________

Work Performed: _______________________________________________________________________________________

_______________________________________________________________________________________________________

If you need additional space, please continue on a separate sheet of paper

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Additional Information

List professional, trade, business or civic activities and offices held.

You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

Other Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.

Specialized Skills (Check Skills/Equipment Operated)

_____ Sign Language _____ Adaptive/Assistive Technology _____ Word Processing (List programs

_____ Behavior Management _____ Inclusive Education you are familiar with)______________

_____ Collaboration (Team Skills) ________________________________

_____ Leisure Skills (please list) Other____________________________

__________________________ ________________________________

__________________________ ________________________________

State any additional information you feel may be helpful to us in considering your application.

References

1. Name: _________________________________________________ Phone: ___________________________

Address:_____________________________________________________________________________________

2. Name: _________________________________________________ Phone: ___________________________

Address:_____________________________________________________________________________________

3. Name: _________________________________________________ Phone: ___________________________

Address:_____________________________________________________________________________________

4

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.

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

_____________________________________ ______________

Signature of Applicant Date

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