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PRE-APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

 

_____________________________________________________________                                                       ______________________________

NAME (LAST NAME FIRST)                                                                                                                                          SOCIAL SECURITY NUMBER

 

_____________________________________________________                            __________________________________________________

PRESENT ADDRESS, CITY, STATE, ZIP                                                                               PERMANENT ADDRESS, CITY, STATE, ZIP

 

_____________________________________

TELEPHONE/CELL PHONE NUMBER

 

DESIRED EMPLOYMENT

 

__________________________________________                             ____________________                                __________________________

POSITION                                                                                                DATE YOU CAN START                                    SALARY DESIRED

 

___________________                                   ________________________________________________________________________________

ARE YOU EMPLOYED NOW?                          MAY WE CONTACT YOUR PRESENT EMPLOYER? IF NO WHY?

 

___________________                                    ________________________________________________________________________________

EVER WORKED FOR                                          IF YES, WHEN?

THIS COMPANY

 

EDUCATION

 

GRAMMAR SCHOOL:__________________________________________________________________________________________________

                                      (NAME/LOCATION/YEARS OF ATTENDANCE/DID YOU GRADUATE?)

 

HIGH SCHOOL:______________________________________________________________________________________________________

                             (NAME/LOCATION/YEARS OF ATTENDANCE/DID YOU GRADUATE?)

 

COLLEGE:__________________________________________________________________________________________________________

                    (NAME/LOCATION/YEARS OF ATTENDANCE/DID YOU GRADUATE?)

 

FORMER EMPLOYER

 

__________________________________________________________________________________________________________________

PRESENT/LAST EMPLOYER-ADDRESS-PHONE

 

_____________________________________________________                                                                  _________________________________

POSITION                                                                                                                                                                           STARTING/ENDING PAY

 

______________________________________________________

STARTING DATE AND LEAVING DATE

 

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DESCRIPTION OF WORK

 

______________________________________________________________________________________________________________________

REASON FOR LEAVING

 

I CERTIFY THAT THE FACTS CONTATINED IN THIS PRE-APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.  I UNDERSATND THAT I WILL BE REQUIRED BY BIG ELM REHABILITATION AND LIVING CENTER TO PROVIDE A COMPLETE APPLICATION AND/OR RESUME.

 

PLEASE PRINT AND/OR SAVE THIS AND FORWARD TO LYNNETTE GEARING AT (bigelmpayroll@ctc.net).