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APPLICATION FOR EMPLOYMENT

Position Applied For:


PERSONAL INFO:

First Name:
Middle Name:
Last Name:
Suffix:
Present Street Address:
City:
State:
Zipcode:
Home Phone:
Work Phone:
Cell Phone:

Email Address:





EDUCATION:

SCHOOL ATTENDED

COURSE OF STUDY

YEARS COMPLETED

DIPLOMA OR DEGREE


Degree GED High School Trade/Vocational School Associate Degree Bachelor's
Degree Masters Degree Doctoral Degree Other








CERTIFICATIONS:

Please list any certifications you may have.


MILITARY SERVICE:

Have you had job related training in the United States military?

No
Yes

If yes, please describe.


EMPLOYMENT HISTORY:

Start with the most recent or present employer - including Military Service.

Remove
Employer:
Date Hired:

Date Left:

Address:
Salary or Hr. Rate:
Salary or Hr. Rate:
Name Under Which Employed (if different from present):
Employer’s Phone:


JOB TITLE AND DESCRIPTION OF DUTIES:

Immediate Supervisor (name and position):


REASON FOR LEAVING:



What is your annual salary expectation for this position?

Select a salary range $30,000 to $35,000 $35,000 to $40,000 $40,000 to $45,000
$45,000 to $50,000 $50,000 to $55,000 $55,000 to $60,000 $60,000 to $65,000
$65,000+


PROFESSIONAL ACTIVITIES

List professional, trade, or business activities and offices held.


SPECIAL SKILLS AND QUALIFICATIONS/OTHER JOB RELATED TRAINING

Summarize special job-related skills and qualifications acquired from employment
or other experience.

Are you 18 years of age?

No
Yes

Are you authorized to work in the United States?
Proof of current authorization to work will be required upon employment.

No
Yes

Have you previously filed an application with Citizens?
If yes, give the date (s).

No
Yes

If you receive a conditional offer of employment, will you submit to the post
offer physical assessment for the job offered and a test for the illegal use of
drugs, at the expense of Citizens?

No
Yes

Have you been disciplined, or involuntarily separated by an employer in the past
5 years?
If yes, please explain.

No
Yes

Have you been convicted of a felony?
Conviction will not necessarily disqualify a candidate/applicant from
employment.
If yes, please list conviction date and type of conviction.

No
Yes

May we conduct a detailed reference check?
If yes, please indicate any employers you do not want us to contact and reason.

No
Yes

Are you related to anyone working at Citizens or Member of the Board of
Directors?
If yes, please list.

No
Yes

Where did you hear about this job?




REFERENCES:

Give name, address, and telephone number of three references who are not related
to you.

NAME

ADDRESS

PHONE NUMBER




COVER LETTER

Please upload your cover letter

Choose a file…


RESUME

Please upload your Resume

Choose a file…

I have read and understand the Candidate's/Applicant's Certification and
Agreement and certify the information I have provided in my employment
application is true and complete.

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