SERRC
210 FERRY WAY
JUNEAU, ALASKA 99801
907.586.6806
907.463.3811 fax

Application for Employment

Employment Desired

Position:
Personal Information
Last Name:
 First Name:
 Middle:

Social Security Number (*last four digits):

Street Address:

City :    State : ZIP :

Email:         Telephone # Home:   Work:

How did you hear of this position?:

When can you start?:

Salary desired:

Are you applying for a position listed on the SERRC web site?
Yes:  No:

 

Have you ever applied with SERRC before?:
Yes:     No:        If so...when?:

 

Have you been told the essential functions of the job or have you been shown a copy of the job description listing the essential functions of the job?
Yes:     No:

 

CONVICTIONS

Have you ever been convicted of a felony?
Yes:     No:      

Have you been convicted of a misdemeanor within the past 5 years?
Yes:     No:

Are you currently under arrest or indictment for any violation of law?
Yes:     No:

If the answer to any of the above is 'yes', please explain below:

(Conviction is not an automatic bar to employment. Failure to disclose information in response to the above is grounds for denying employment.)

 

Education

Do you have a high school diploma or GED certificate? Yes:     No:

High School Name:

Address:

Graduated:

Yes:

 No:

Subjects Studied/
Degrees Received:
College Name:

Address:

Graduated:

Yes:

 No:

Subjects Studied/
Degrees Received:
Trade, Business or Correspondence School:

Address:

Graduated:

Yes:

 No:

Subjects Studied/
Degrees Received:

Special Study/Research/Training :

Special Interests/Certificates/Experiences:

EMPLOYERS

May we contact your present employer?  
Yes:  No:

May we contact your previous employers?  
Yes:  No:

Current/Recent Employer:  

Address:

Date Started:   Date Left:   Pay Rate:  per:  

Supervisor:   Phone:

Position Title:   Reason for Leaving:

______________________________________________________________

Previous Employer :

Address:

Date Started:   Date Left:   Pay Rate:  per:  

Supervisor:   Phone:

Position Title:   Reason for Leaving:

______________________________________________________________

Previous Employer:

Address:

Date Started:   Date Left:   Pay Rate:  per:  

Supervisor:   Phone:

Position Title:   Reason for Leaving:

______________________________________________________________

Previous Employer:  

Address:

Date Started:   Date Left:   Pay Rate:  per:  

Supervisor:   Phone:

Position Title:   Reason for Leaving:

 

Professional References

Please name three persons, not related to you, whom you have known for at least one year and who can comment on your professional abilities as related to this job vacancy.

Name:
 Address:
 Business Phone:
 Home Phone:
 Relationship:
Name:
 Address:
 Business Phone:
 Home Phone:
 Relationship:
Name:
 Address:
 Business Phone:
 Home Phone:
 Relationship:

I hereby cerify that all information made on or in connection with this application is true and complete to the best of my knowledge and belief. I understand that any misrepresentation or concealment of material fact will be sufficient ground for rejection of my application or dismissal from employment. I authorize investigation of all statements made in this application, I understand and agree that my employment lasts for no definite period of time and may, regardless of the date of of payment of my wages or salary, be terminated at any time without previous notice.

Yes:  No:

  Signed:     


It is SERRC policy to provide equal employment opportunity to all persons and to prohibit discrimination due to race, color, religion, sex, age, marital status, disability, sexual orientation or national origin.