Name:                       Social Security #   

                Other names used:    Home Phone:

                Address:                      Business Phone:

                Position applying for:

                Referred by:       Salary desired: per hour year

                Are you at least 25 years old? Yes No

                Do you have a current, valid driver's license? Yes No

                Have you ever been employed by Harris Home for Children before? Yes No

                If yes, list date(s) and job title(s)

                Have you ever been convicted of any violation(s) of law, including moving traffic violations?

                Yes No

                If yes, please provide all pertinent information. 

                Education         

                High School     

                School Name:

                Address:       

                Did you graduate? Yes  No

                College/University

                School Name:

                Address:

                Major Studies:

                Degree, Diploma, License or Certificate obtained:

                Vocational, Business, Other

                School Name:

                Address:

                Major Studies:

                Degree, Diploma, License or Certificate obtained:

                List any professional Affiliations

                Other special knowledge, skills or qualifications:

                All applicants are afforded equal opportunity in all aspects of employment without regards to race, color,

   religion, political affiliation, national origin, disability, marital status, gender or age.

                Employment History

                List last 3 employers, starting with the most recent position.  All information must be completed. 

                Employer #1

                Start date: month/year

                End date: month/year or PRESENT

                Employer name:

                Employer address:

                Supervisor name:

                Supervisor phone:

                Job Title:   

                Duties and Responsibilities:

                Starting salary: per hour year

                Ending salary:   per hour year

                Reason for leaving:

                Employer #2

                Start date: month/year

                End date: month/year

                Employer name:

                Employer address:

                Supervisor name:

                Supervisor phone:

                Job Title:   

                Duties and Responsibilities:

                Starting salary: per hour year

                Ending salary:   per hour year

                Reason for leaving:

                Employer #3

                Start date: month/year

                End date: month/year

                Employer name:

                Employer address:

                Supervisor name:

                Supervisor phone:

                Job Title:   

                Duties and Responsibilities:

                Starting salary: per hour year

                Ending salary:   per hour year

                Reason for leaving:

                Personal References (3)

                Reference #1

                   Name:             Years known:

                Address:                             Phone:

                Reference #2

                  Name:             Years known:

                Address:                             Phone:

                Reference #3

                  Name:             Years known:

                Address:                             Phone:

I hereby authorize Harris Home for Children to investigate my references and to make an independent investigation of my character, conduct, and employment records.  I agree that the above information is true and correct.  I understand that, in the event of my employment by Harris Home for Children, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery.  I hereby acknowledge that I have read and agree to the above statements.        

Yes, I agree  No, I do not agree 

Date: mm/dd/yyyy