LAUREL HOUSE, INCORPORATED
       Rear 197 West Main Street        Phone:  724-437-1129
       Uniontown, PA 15401                FAX :      724-438-0323
               AN EQUAL OPPORTUNITY EMPLOYER

 APPLICATION FOR EMPLOYMENT

      DATE: ___________

      PERSONAL

NAME
STREET SOCIAL SECURITY #
CITY HOME PHONE
STATE                                            ZIP BUSINESS PHONE

      EDUCATION 

NAME AND LOCATION

FROM

TO

DEGREE/MAJOR/GPA

DATE GRADUATED
HIGH SCHOOL        
COLLEGE        
OTHER        

      SPECIAL SKILLS OR TRAINING   (APPLICABLE TO EMPLOYMENT)    

 
 

      EMPLOYMENT  (START WITH MOST RECENT) 

FROM               TO                    EMPLOYER                                                                                PHONE #
JOB TITLE                                               DUTIES
SUPERVISOR'S NAME
STARTING SALARY
ENDING SALARY                                        REASON FOR LEAVING

MAY WE CONTACT EMPLOYER AT ABOVE PHONE NUMBER?             o  YES               o   NO
 
FROM              TO                    EMPLOYER                                                                                  PHONE#
JOB TITLE                                               DUTIES
SUPERVISOR'S NAME
STARTING SALARY
ENDING SALARY                                        REASON FOR LEAVING

MAY WE CONTACT EMPLOYER AT ABOVE PHONE NUMBER?             o  YES               o   NO

 
FROM              TO                  EMPLOYER                                                                                  PHONE #
JOB TITLE                                               DUTIES
SUPERVISOR'S NAME
STARTING SALARY
ENDING SALARY                                        REASON FOR LEAVING

MAY WE CONTACT EMPLOYER AT ABOVE PHONE NUMBER?             o  YES               o   NO

      MILITARY

BRANCH RANK DUTIES SALARY
FROM             TO		 REASON FOR CHANGE IN RANK
         
         
         
         

LIST SPECIAL SCHOOLING AND SKILLS ACQUIRED DURING MILITARY SERVICE
 
 

      ADDITIONAL DATA

POSITION APPLIED FOR:
SCHEDULE DESIRED:                            o   FULL TIME                          o     PART TIME                               o     TEMPORARY
LIST ANY DAYS/HOURS YOU ARE UNABLE TO WORK:
RATE OF PAY DESIRED:
HOW DID YOU HEAR ABOUT THIS JOB?
HAVE YOU WORKED HERE BEFORE?                                         o    YES               o     NO
          IF YES, HOW LONG?
          PREVIOUS POSITION:                                       REASON FOR LEAVING:
LIST ANY FRIENDS OR RELATIVES WORKING WITH US NOW:

      PERSONAL REFERENCES

           NAME                               ADDRESS                                                       RELATIONSHIP                         PHONE
 
 
 

LIST ONLY PERSONS WE MAY CONTACT (BE SURE TO INCLUDE PHONE NUMBER)

              APPLICANT:  Read and Sign Below

             The information provided by me in this application for employment is true and complete to the best of my knowledge.
              I AGREE TO   HOLD HARMLESS AND FREE FROM LIABILITY AND REFERENCE FOR THE INFORMATION
             THEY MAY GIVE THE AGENCY PERTAINING TO MY EMPLOYMENT.

              APPLICANT SIGNATURE ___________________________________________ DATE __________________

 

 

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