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Employment Application

An Equal Opportunity Employer.

Date:
Name:
Nickname/Maiden Name:
Address:
City:
State:
Zip Code:
Home Phone:
Other:
Email:

Occupational Data

Job wanted:
What wage do you expect?
When are you available for work?
Will you work overtime if asked?	Yes No
Special training or skills?
Have you ever applied with us before?	Yes No When?
Have you ever worked with us before?	Yes No When?
Supervisor/Department Head
Why did you leave?

Employment:

List your last or present job first and then others in order back from that one. List all former employment.

JOB 1

Company Name:
Company Address:
Company #:
Started Month/Year:
Left Month/Year:
Supervisor's Name:
What was your job?
Why did you leave?

JOB 2

Company Name:
Company Address:
Company #:
Started Month/Year:
Left Month/Year:
Supervisor's Name:
What was your job?
Why did you leave?

JOB 3

Company Name:
Company Address:
Company #:
Started Month/Year:
Left Month/Year:
Supervisor's Name:
What was your job?
Why did you leave?

Educational Data:

Last grade completed.

Grammar School:	1 2 3 4 5 6 7 8
High School:	1 2 3 4
College:	1 2 3 4
Trade School:	1 2 3 4
Correspondence School:	1 2 3 4
Special training or skills?

Payroll, tax and insurance information:

List members of immediate family and household below.

Relation - Name:	Dependent on you:
Name:
Nickname/Maiden Name:
Address:
City:
State:
Zip Code:
Home #:
Other:

General Information:

Are you registered with the State Unemployment service?	Yes No Where?
Have you ever been convicted of a felony?*	Yes No
If the answer is yes, explain:

*Conviction of a crime will not automatically disqualify you from the job for which you are applying. Each conviction will be considered in respect to time, job relatedness and other relevant factors.

List of names of persons employed by us (if any) who can confirm the information on this application.

Employee Name:	Occupation:	How long known?

Employee Name:	Occupation:	How long known?

Employee Name:	Occupation:	How long known?

Employee Name:	Occupation:	How long known?

Personal References:

Do not use relatives or former employers.

Name:	Number:	Occupation:	How long known?

Name:	Number:	Occupation:	How long known?

Name:	Number:	Occupation:	How long known?

Name:	Number:	Occupation:	How long known?

Military Service:

Branch of Service:	Reserve Status:	Date of Entry:	Date of Discharge:

Branch of Service:	Reserve Status:	Date of Entry:	Date of Discharge:

Branch of Service:	Reserve Status:	Date of Entry:	Date of Discharge:

Branch of Service:	Reserve Status:	Date of Entry:	Date of Discharge:

In case of emergency notify:

Name:
Relationship:
Address:
Phone #:
Other:

Authorization to release employment reference information

I understand that the Atlanta Humane Society will attempt to verify statements made on my application and made during my employment interview. When contacted by the Atlanta Humane Society, I give my permission for my former employers to answer any and all questions based upon information available to them in my prior employment records. I understand that it is possible that my prior employment records may not be accurate. Nonetheless, in consideration of the Atlanta Humane Society's review of this application, I release the Atlanta Humane Society and all former employers for any liability as a result of the furnishings and receiving of this reference information. I understand that my failure to sign this reference release so the Atlanta Humane Society
can contact references and make a full background check of my previous work history will be regarded as a withdrawal of my application for employment.

We are an equal opportunity employer. I understand that this application is not an offer of employment, does not mean that any positions are available, and does not guarantee that I will be offered a job. I also understand that if hired, the Atlanta Humane Society may change the terms and conditions of my employment, if necessary and appropriate, that any employment is for an indefinite period of time, and that both the Atlanta Humane Society and I have the freedom to terminate such employment relationship whenever either choose to do so, with or without cause and with or without notice. I further understand and acknowledge that no representative of the Atlanta Humane Society, other than the President, has any authority to enter into any agreement that is contrary to the language of this application.

I understand that material omissions or false statements on this application may be considered sufficient cause for denial of employment or dismissal, if and when discovered.

I also authorize the Atlanta Humane Society to contact the references and former employers listed.

I understand that I will be required to undergo a drug screening test and a background check which follows the Fair Credit Reporting Act guidelines as part of my employment process. An offer of employment will be withdrawn when the results of the drug screening test is positive for illegal drugs or for the presence of prescription drugs (such as barbiturates, amphetamines, opiates, etc.) unless I have a current prescription and a valid medical reason for the use of such drugs.

The Atlanta Humane Society shall not discriminate on the basis of age, sex, race, color, creed, national origin, religion, or disability with regard to receipt of services or hiring and promotion in staff positions.

This application becomes void after 60 days unless renewed in writing accept the terms of the following:

Signature: Date: