Employment Application

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Personal Information

Application for *

Full Time

Part Time

Volunteer

Internship, please indicate semesterInternship, please indicate semester

Position *

Name *

Last

First *

First

Middle *

Middle

Phone Number *

Address *

City *

State *

Zip Code *

E-mail Address *

Education

High School *

School & Location

Degree Earned

Course of study/major

Years Completed

Did you graduate?

Yes

No

College

School & Location

Degree Earned

Course of study/major

Years Completed

Did you graduate?

Yes

No

Graduate School

School & Location

Degree Earned

Course of study/major

Years Completed

Did you graduate?

Yes

No

Other Schools

School & Location

Degree Earned

Course of study/major

Years Completed

Did you graduate?

Yes

No

Name of school, college, or university last attended

Professional licenses and/or certificates

Disclosures

Are you at least 21 years of age? *

Yes

No

Are you legally eligible for employment in the United States? *

Yes

No

Has your driver’s license been suspended or revoked within the past 3 years? *

Yes

No

Please note: Driver’s license suspensions/revocations do not automatically reject an applicant.

Do you have a current Illinois driver’s license? *

Yes

No

List other state of license, if applicable:

Employment History

Past 10 years, most recent employer first

Employer *

Telephone *

please include area code

Job Title(s) *

Supervisor *

Date Started *

Are You Currently Working At This Job? *

Yes

No

Date Left *

May we contact employer? *

Yes

No

Later

Duties *

Reason for leaving *

Employer

Telephone

please include area code

Job Title(s)

Supervisor

Date Started

Are You Currently Working At This Job?

Yes

No

Date Left

May we contact employer? *

Yes

No

Later

Duties

Reason for leaving

Employer

Telephone

please include area code

Job Title(s)

Supervisor

Date Started

Are You Currently Working At This Job?

Yes

No

Date Left

May we contact employer? *

Yes

No

Later

Duties

Reason for leaving

ADDITIONAL EXPERIENCE OR OTHER INFORMATION YOU WOULD LIKE US TO CONSIDER:

Additional Employment History

Employer

Telephone

please include area code

Job Title(s)

Supervisor

Date Started

Are You Currently Working At This Job?

Yes

No

Date Left

May we contact employer? *

Yes

No

Later

Duties

Reason for leaving

ADDITIONAL EXPERIENCE OR OTHER INFORMATION YOU WOULD LIKE US TO CONSIDER:

Add Remove

Professional References

Please list three people, not related to you, who can provide information as to your experience, training, skills, and/or character. (Examples: Employers, supervisors, teachers, mentors, or co-workers.)

Name *

E-mail Address *

Relationship *

Phone Number *

Name-2 *

E-mail Address-2 *

Relationship-2 *

Phone Number-2 *

Name-3 *

E-mail Address-3 *

Relationship-3 *

Phone Number-3 *

Why

How did you hear about this job opening?

Why are you interested in employment at Project Oz?

Signature

Certification of Information: I hereby certify that the information contained in this application is correct to the best of my knowledge and understand that deliberate falsification of this information may be grounds for dismissal.

Applicant's Signature *

Date *

Authorization for Release of Information

I hereby authorize Project Oz to obtain and verify verbally or in writing such information about my background and qualifications for employment at Project Oz, in its sole discretion, deems relevant to its decision whether to hire me for the position I am applying for, including without limitation professional and personal references, employment verifications, educational verifications, license and credentials verifications, criminal records, motor vehicle records, and Social Security number verifications.

In regards to Project Oz considering my application for employment, I hereby release Project Oz and its officers, directors, agents, and employees from any and all claims I may have arising out of the obtaining and verification of such information.

I hereby authorize any and all persons to disclose information to Project Oz about my previous employment or suitability for future employment.

In consideration of any person agreeing to provide information to Project Oz as authorized by this form, I hereby release any such person and any affiliated officers, directors, agents, and employees from any and all claims I may have arising out of the disclosure of such information.

Applicant's Signature *

Date *

Please list any previous and/or maiden names, if applicable

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Employment Application

Uploads

Personal Information

Education

Disclosures

Employment History

Additional Employment History

Professional References

Why

Signature

Authorization for Release of Information

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