Employment

Position Applying For*

Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Social Security Number

If you are not comfortable submitting via this online form, you'll be asked to show proof of identification.

Are you legally eligible for employment in the U.S.A.?*

If yes, verification will be required.

Yes
No

Are you seeking a permanent position?*

Yes
No

Are you able to perform the essential functions of the position with or without accommodations?*

Yes
No

What shifts are you able to work?

Use the Shift+Control keys to select multiple choices.

Are you able to work overtime?

Yes
No

Are you able to provide a valid Alaska Drivers License?

Yes
No

If necessary for the job, are you over the age of:

I will be able to report to work ___ days after being notified that I am hired.

Education

Name/Type of School	Years Completed	Field of Study/Degree

Military Service

Yes
No

Duty/Specialized Training

References

List two personal references who are not relatives or former supervisors.

Name	Address	Telephone	Occupation	Years Known

List last employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here or in the summary (next section).

Employer Name

Address

Street Address City State / Province / Region

Position Title/Duties and Skills

Employment Dates

From To

Reason for leaving

Supervisor

Name Phone Number

Employer Name

Address

Street Address City State / Province / Region

Position Title/Duties and Skills

Employment Dates

From To

Reason for leaving

Supervisor

Name Phone Number

Employer Name

Address

Street Address City State / Province / Region

Position Title/Duties and Skills

Employment Dates

From To

Reason for leaving

Supervisor

Name Phone Number

Do you need more space for employment history?

Yes
No

Employer Name

Address

Street Address City State

Position Title/Duties and Skills

Employment Dates

From To

Reason for leaving

Supervisor

Name Phone Number

Employer Name

Address

Street Address City State

Position Title/Duties and Skills

Employment Dates

From To

Reason for leaving

Supervisor

Name Phone Number

Summarize any other employment related to this job:

Types of computers, other electronic or mechanical equipment that you are qualified to operate or repair:

Typing speed (words per minute):

Professional Licenses, Certifications or Registrations:

Additional skills including supervision skills, other languages, or information regarding the career/occupation you wish to bring to the employer's attention:

In case of accident or illness, please contact:

Name	Address	Daytime Phone	Relationship

Information to the applicant: As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references.

If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the US, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms.

I understand and agree to the information shown above:

Electronic Signature*

Date*

Equal Employment Opportunity: While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment.

Employment Application

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Education

References

Employment

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