APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

DATE

NAME (LAST NAME FIRST)

MAY 1,
SOCIAL SECURITY NO.

2017

Field, Chelsea
PRESENT ADDRESS

CITY

STATE

ZIP CODE

P.O. Box 127

East Hardwick

VT

05836

PERMANENT ADDRESS

CITY
East Hardwick

STATE
VT

ZIP CODE
05836

1603 Bayley Hazen Road

PHONE NO.

REFERRED BY

Beth Weatherbee

(802) 535-8469
EMPLOYMENT DESIRED
POSITION

DATE YOU CAN START

SALARY DESIRED

Licensed Nurse Assistant

May 31, 2017

Negotiable

ARE YOU
EMPLOYED?

x YES

EVER APPLIED TO
THIS COMPANY BEFORE?

IF SO, MAY WE INQUIRE

WITH YOUR PRESENT EMPLOYER?

NO

YES

WHERE?

NAME & LOCATION OF SCHOOL

HIGH SCHOOL

COLLEGE
TRADE, BUSINESS OR
CORRESPONDENCE
SCHOOL

N
O

WHEN?

NO

EDUCATION HISTORY
GRAMMAR SCHOOL

x Y
ES

YEARS
ATTENDED

DID YOU
GRADUATE?

Walden School

9 years

Yes

Hazen Union High School

1 year

Still Attending

Community College of Vermont

1 year

Still Attending

Green Mountain Technology and

Career Center

2 years

Still Attending

SUBJECTS STUDIED

GENERAL INFORMATION

SUBJECTS OF SPECIAL STUDY/RESEARCH

WORK OR SPECIAL TRAINING/SKILLS

AHA CPR for Healthcare Providers and first aid, Licensed Nursing Assistant, Personal
Care Provider, Emergency Medical Responder, College Credit in Medical Terminology
and Human Biology
U.S. MILITARY OR

RANK

Not at this time.

NAVAL SERVICE

FORMER EMPLOYERS
DATE
MONTH AND YEAR

FROM
TO
FROM
TO
FROM

(LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)
POSITIO
NAME & ADDRESS OF EMPLOYER
SALARY
N

REASON FOR LEAVING

TO
FROM
TO

Adams 9661 APR 1998

CONTINUED ON OTHER SIDE
REFERENCES: GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR
NAME

ADDRESS

BUSINESS

Beth Weatherbee

738 VT 15W Hyde Park, VT

05665

Dana Jourdan

738 VTW Hyde Park, VT

05665

Kristin Moodie

21 Munson Ave Morristown

VT, 05661

YEARS
KNOWN

Allied Health Teacher at

Green Mountain Technology
and Career Center
Electrical Teacher at Green
Mountain Technology and
Career Center

Child Care Provider at

Green Mountain Kids

2
1

AUTHORIZATION
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.
I authorize investigation of all statements contained herein and the references and employers listed above to give you
any and all information concerning my previous employment and any pertinent information they may have, personal or
otherwise, and release the company from all liability for any damage that may result from utilization for such information.
I also understand and agree that no representative of the company has any authority to enter into any agreement for
employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing
and signed by an authorized company representative.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by
the Americans with Disabilities Act (ADA) and other relevant federal and state laws.
DATE

SIGNATURE

INTERVIEWED BY

DATE

REMARKS

NEATNESS

CHARACTER

PERSONALITY

ABILITY

HIRED

FOR
DEPT.

POSITION

WILL
REPORT

SALARY
WAGES

APPROVED: 1.

2.
EMPLOYMENT MANAGER

3.
DEPARTMENT HEAD

GENERAL MANAGER

This application for employment is sold only for general use throughout the United States. Adams assumes no responsibility and hereby disclaims any liability for the inclusion in this form of any questions
or requests for information upon which a violation of local, state and/or federal law may be based. It is the users responsibility to ensure that this forms use complies with applicable laws which change
from time to time.