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Dishwasher/Kitchen Helpers, Part Time Seasonal

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General Information

First Name

Last Name

Maiden Name

Address

City

State

Zipcode

Main Phone #

Cell Phone #

May we contact you at work?

Work Phone #

E-mail

If under 18 years of age, please fill out the following information:

Guardian's Name

Guardian's Address

Guardian's Main Phone

Guardian's Cell Phone

Guardian's Work Phone

Employment Questions

Date Available for Work

Former Employee of Rock Springs 4-H Center?

If Yes, Dates of Employment

Are you legally eligible for employment in this country
Yes
No

Have you been convicted of a felony in the last seven years?
Yes
No

If yes, please explain:

Have you ever been convicted of sexual abuse or child abuse?
Yes
No

If yes, please explain:

Are you related to anyone currently employed by Rock Springs 4-H Center or the Kansas 4-H Foundation?

Educational Background

School Name and Location, Years Completed, Degree, Major/Minor, GPA

Other Education & Training: Name of Program, School/Institution, Comments

Skills and Qualifications: Skills, Level, Last Used

Employment History - List your last four employers (if applicable), starting with the most recent, including military experience. Explain any gaps in employment in the comments section below.

Employer #1

Employer Name and Address

Dates Employed

Telephone #

Position (Job Title)

Immediate Supervisor & Title

Reason for Leaving

Beginning wage/salary & ending wage/salary

May we contact for reference

Summarize the nature of the work performed and job responsibilities

Employer #2

Employer Name and Address

Dates Employed

Phone #

Position (Job Title)

Immediate Supervisor & Title

Reason for Leaving

Beginning wage/salary and ending wage/salary

May we contact for reference?

Summarize the nature of the work performed and job responsibilities

Employer #3

Employer Name and Address

Dates Employed

Telephone #

Position (Job Title)

Immediate Supervisor & Title

Reason for Leaving

Beginning wage/salary and Ending wage/salary

May we contact for reference?

Summarize the nature of the work performed and job responsibilities

Employer #4

Employer Name and Address

Dates Employed

Telephone #

Position (Job Title)

Immediate Supervisor & Title

Reason for Leaving

Beginning wage/salary and Ending wage/salary

May we contact for reference?

Summarize the nature of the work performed and job resonsibilities

References

List name and telephone numbers of three business/work references who are not related to you and not shown as immediate supervisor under the Employment History section on the preceding page. If not applicable, list three school or personal references that are not related to you.

1. Name, Telephone #, Years Known

2. Name, Telephone #, Years Known

3. Name, Telephone #, Years Known

It is understood and agreed upon that any misrepresentation by me in this application is sufficient cause for cancellation of this application and/or separation from the employer's services if I have been employed. Furthermore, I understand that just as I am free to resign at anytime, with or without prior notice, the Kansas 4-H Foundation retains the right to lay me off or terminate my employment at any time, with or without cause. I understand that no representative of the Employer has the authority to make any assurances to the contrary. I affirm that I have a genuine intent and no other purposes in applying for a job with this company.

I give the Employer the right to investigate all references and to secure additional information about me, including a criminal background check, driving record check and a drug screen. I hereby release from liability the Employer and its representatives from seeking such information and all other persons, corporation or organizations for furnishing such information.

The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 90 days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to complete a new application.

Signature of applicant and date

Unsigned applications are not considered. You will required to complete an Affirmation of Drug and Alcohol testing policy, drug screening and Voluntary Disclosure prior to employment.

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