EMPLOYMENT / JOB APPLICATION

PERSONAL INFORMATION

FULL NAME: Anna ELIZABETH PAYNE DATE: 9/28/2020

First Middle Last

ADDRESS:
Street Address Apt/Suite

Taylorsville GA
City State Zip Code

E-MAIL: annapayne340@gmail.com PHONE: 706-263-9655

SOCIAL SECURITY NUMBER (SSN):

DATE AVAILABLE: DESIRED PAY: $18.00 ☐ HOUR ☐ SALARY

POSITION APPLIED FOR: Phlebotomist

EMPLOYMENT DESIRED: ☐ FULL-TIME ☐ PART-TIME ☐ SEASONAL

EMPLOYMENT ELIGIBILITY

ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S? ☐ YES ☐ NO*

HAVE YOU EVER WORKED FOR THIS EMPLOYER? ☐ YES* ☐ NO

*IF YES, WRITE THE START AND END DATES: ____________________________________

HAVE YOU EVER BEEN CONVICTED OF A FELONY? ☐ YES* ☐ NO

*IF YES, PLEASE EXPLAIN: ____________________________________________________

EDUCATION

HIGH SCHOOL: Woodland High School CITY / STATE: Cartersville, GA

FROM: 2017 TO: 2021

GRADUATE? ☐ YES ☐ NO DIPLOMA: _____________________

COLLEGE: _____________________ CITY / STATE: _____________________

FROM: _____________________ TO: _____________________

GRADUATE? ☐ YES ☐ NO DEGREE: _____________________

OTHER: Bartow County College & Career CITY / STATE: Cartersville, GA

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FROM: 2019 TO: 2021

DEGREE/CERTIFICATION: Phlebotomy/EKG

OTHER: _____________________ CITY / STATE: _____________________

FROM: _____________________ TO: _____________________

DEGREE/CERTIFICATION: _____________________

PREVIOUS EMPLOYMENT

EMPLOYER 1: Appalachian Grill

Company / Individual

E-MAIL: __________________________________ PHONE: 770-607-5357

ADDRESS: 14 E Church St
Street Address Apt/Suite

Cartersville GA 30120
City State Zip Code

STARTING PAY: $2.12 ☐ HOUR ☐ SALARY ENDING PAY: $2.12 ☐ HOUR ☐ SALARY

JOB TITLE: Hostess RESPONSIBILITIES: sit costumers, server assistant, clean

restaurant

FROM: 2019 TO: 2021

REASON FOR LEAVING: Wish to pursue a job in the medical feild

EMPLOYER 2: __________________________________________________________
Company / Individual

E-MAIL: __________________________________ PHONE: _____________________

ADDRESS: ____________________________________________________________
Street Address Apt/Suite

____________________________________________________________
City State Zip Code

STARTING PAY: $_________ ☐ HOUR ☐ SALARY ENDING PAY: $_________ ☐ HOUR ☐ SALARY

JOB TITLE: ______________ RESPONSIBILITIES: _____________________________

FROM: _____________________ TO: _____________________

REASON FOR LEAVING: _______________________________________________________

EMPLOYER 3: __________________________________________________________

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 Company / Individual

E-MAIL: __________________________________ PHONE: _____________________

ADDRESS: ____________________________________________________________
Street Address Apt/Suite

____________________________________________________________
City State Zip Code

STARTING PAY: $_________ ☐ HOUR ☐ SALARY ENDING PAY: $_________ ☐ HOUR ☐ SALARY

JOB TITLE: ______________ RESPONSIBILITIES: _____________________________

FROM: _____________________ TO: _____________________

REASON FOR LEAVING: _______________________________________________________

REFERENCES
(PROFESSIONAL ONLY)

FULL NAME: Jan Miracle RELATIONSHIP: Manager

First Last

COMPANY: Appalachian Grill TITLE: Restaurant Manager

E-MAIL: __________________________________ PHONE: 770-607-5357

FULL NAME: Malachi Debroux RELATIONSHIP: Friend

First Last

COMPANY: Southeastern roofing TITLE: sales manager

E-MAIL: __________________________________ PHONE: 470-232-2936

FULL NAME: Janice Adams RELATIONSHIP: Friend

First Last

COMPANY: Home Health TITLE: RN

E-MAIL: __________________________________ PHONE: 678-882-2087

MILITARY SERVICE

ARE YOU A VETERAN? ☐ YES ☐ NO

BRANCH: _____________________ RANK AT DISCHARGE: _____________________

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FROM: _____________________ TO: _____________________

TYPE OF DISCHARGE: _____________________

IF NOT HONORABLE, PLEASE EXPLAIN: ______________________________________

BACKGROUND CHECK CONSENT

IF ASKED, ARE YOU WILLING TO CONSENT TO A BACKGROUND CHECK? ☐ YES ☐ NO

DISCLAIMER

Applicant understands that this is an Equal Opportunity Employer and committed to excellence
through diversity. In order to ensure this application is acceptable, please print or type with the
application being fully completed in order for it to be considered.

Please complete each section EVEN IF you decide to attach a resume.

I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this
application leads to my eventual employment, I understand that any false or misleading
information in my application or interview may result in my employment being terminated.

SIGNATURE _________________________________ DATE 9/28/2020

PRINT NAME ANNA PAYNE

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