Employment Application

Name *

First

Last

Address *

Phone Number *

Position applied for?

Have you filed an application here before? *

If YES, please give date.

Have you ever been employed here before? *

If YES, please give date.

Are you employed now? *

May we contact your present employer? *

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? *

(Proof of citizenship or immigration status will be required upon employment.)

On what date would you be available to work? *

Are you available to work *

Full-Time
Part-Time
Shift Work
Temporary

Are you on lay-off and subject to recall? *

Can you travel if the job requires it? *

Have you been convicted of a felony within the last 7 years? *

If YES, please describe.

(A conviction record will not necessarily bar employment with the department.)

Veteran of the U.S. Military Service? *

If YES, Branch

If hired, would you be able to perform all functions and all necessary job assignments of the particular job for which you are applying? If not, please explain. *

Indicate what foreign languages you speak, read, and/or write FLUENTLY. *

(When related to the position sought.)

Indicate what foreign languages you speak, read, and/or write WELL. *

(When related to the position sought.)

Indicate what foreign languages you speak, read, and/or write FAIR. *

(When related to the position sought.)

If you have ever belonged to a professional trade, business, or civic activity or held an office in such a club or organization and you believe that your experience would be relevant to the job for which you have applied, you may describe it here.

(Where the name of the organization or club indicates your race, gender, color, religion, national origin or ancestry, please do not write down its name; instead, please describe your position in the organization.)

Special Skills and Qualifications - Summarize special skills and qualifications acquired from employment or other experience.

[1] Previous Employer

[1] Work Performed

[1] Dates Employed from start date to end date

[1] Address

[1] Job Title

[1] Supervisor

[1] Reason for leaving

[2] Previous Employer

[2] Work Performed

[2] Dates Employed from start date to end date

[2] Address

[2] Job Title

[2] Supervisor

[2] Reason for leaving

[3] Previous Employer

[3] Work Performed

[3] Dates Employed from start date to end date

[3] Address

[3] Job Title

[3] Supervisor

[3] Reason for leaving

ELEMENTARY School name and years completed, course of study, describe specialized training, and honors received.

HIGH SCHOOL School name and years completed, course of study, describe specialized training, and honors received.

COLLEGE School name and years completed, course of study, describe specialized training, and honors received.

GRADUATE School name and years completed, course of study, describe specialized training, and honors received.

Referral source

Applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, gender, national origin, age, marital or veteran status, ancestry, unfavorable discharge from the military, medical condition or handicap. As employers/government contractors, we comply with government regulations and affirmative action responsibilities. To help us comply with government record keeping, reporting and other legal requirements, we request that you fill out this Applicant Data Record. An applicant’s provision of this information is voluntary and is not required in order to be considered for employment at SouthCom. We appreciate your cooperation. This data is for periodic government reporting and will be kept in a Confidential File.

Gender

Male
Female

Affirmative Action Survey: Government agencies require periodic reports on the gender, ethnicity, handicapped and veteran status of applicants. This data is for analysis and affirmative action only. Submission of information about a handicap is voluntary.

Islander Check if any of the following are applicable.

Vietnam Era Veteran
Disabled Veteran
Handicapped Individual

Signature of Applicant *

I certify that information contained in this application is true and complete to the best of my knowledge. I understand that any misrepresentation of fact, as stated or implied, given in my application, interview(s), or other employment forms will be sufficient reason not to hire me and may result in my discharge if I am hired. I authorize investigation of all statements contained in this application as may be necessary in arriving at an employment decision. I understand that I waive any rights I may have to receive notice from any persons listed on this application regarding the release of information relating to this application for employment with SouthCom. I understand that SouthCom is in no way obligated to provide employment and that I am in no way obligated to accept employment with SouthCom. Nothing in this application is intended to create any contract of employment, expressed or implied, or to create any rights in the nature of a contract of employment. This application does not bind either party for a specific period of time regarding employment. If I am hired, nothing shall restrict my right as an employee to terminate my employment at any time, nor shall anything restrict the right of SouthCom to terminate my employment at any time at the option of SouthCom. I also understand that, if hired, I am required to abide by all rules and regulations of SouthCom. SouthCom policies and procedures relating to conditions of employment are subject to modification by SouthCom without notice.

Date of Application *