Fly By Night Publishing

Application For Employment

Please complete all information on this application form. A resume may be attached for additional information by sending and email to admin@connectedness.org.
 

Name

 

(Last)

(First)

(M.I.)
     

Social Security #:

Today’s Date:

 
     

Current Address:

 

 

 
 

(Street)

(City)

(State)

(Zip.)
   

Telephone #:

Message Phone #:

 

Work Preferences And Availability:

Position(s) Applying For: (List the specific position(s) for which you are applying)

  Pay Rate Desired: 

Time of Employment Sought:

Shift(s) You Are Able to Work:

Full-time

Days

Other, Please Specify Below

Part-time

 # of Days Per Wk

Evenings

Either

  

Nights

  

Days Unable to Work:

Date Available To Begin Work:

             

Do you have any disability which would hinder your performance of the Essential Duties of the job(s) for which you are applying?

Yes No

  

If so, what reasonable accommodations may be made to enable you to perform the Essential Duties?

Are you legally eligible to be employed in the U.S.A.?:

Yes

No

Are you 18 years of age or older?"

Yes

No

Have you ever been convicted of a crime?:

Yes

No

If Yes, Offense(s):

 

Location:

Date:

                       

Employment

Account For Your Complete Employment History Beginning With The Present Or Most Recent First. We may contact the employers listed below unless you indicate those you do not want us to contact.
   

Company Name

 

Telephone

(  )

Address (include full street address, city, state, zip)

 

Employed – (State month and year)

From        To 

Name of Supervisor

Pay Rate

Start   End

State Job Title and Describe Your Work

 

Reason for Leaving

 

May We Contact?         Yes      No

If No, give reason:

 

   

Company Name

 

Telephone

(  )

Address (include full street address, city, state, zip)

 

Employed – (State month and year)

From    To

Name of Supervisor 

Pay Rate

Start  End

State Job Title and Describe Your Work

 

Reason for Leaving

 

May We Contact?         Yes       No

If No, give reason:

 

   

Company Name

 

Telephone

(  )

Address (include full street address, city, state, zip)

 

Employed – (State month and year)

From   To

Name of Supervisor

Pay Rate

Start    End

State Job Title and Describe Your Work

 

Reason for Leaving

 

May We Contact?         Yes      No

If No, give reason:

 

   

Company Name

Telephone

( )

Address (include full street address, city, state, zip)

Employed – (State month and year)

From   To

Name of Supervisor

Pay Rate

Start    End

State Job Title and Describe Your Work

Reason for Leaving

May We Contact?         Yes      No

If No, give reason:
   

Company Name

Telephone

( )

Address (include full street address, city, state, zip)

Employed – (State month and year)

From To

Name of Supervisor

Pay Rate

Start    End

State Job Title and Describe Your Work

Reason for Leaving

May We Contact?         Yes      No

If No, give reason:
   

Company Name

Telephone

( )

Address (include full street address, city, state, zip)

Employed – (State month and year)

From To

Name of Supervisor

Pay Rate

Start  End

State Job Title and Describe Your Work

Reason for Leaving

May We Contact?         Yes      No

If No, give reason:
   

Please list any other information that would help us evaluate your qualifications for employment:

Personal Data:

Where Did You Hear About This Opening?: 

Do You Have Friends or Relatives Employed at our Facility?: 

  Yes  No – If Yes, state:

Person’s Name:

Relationship:

Person’s Name:

Relationship:

Education

School

Name & Location

Course of Study

#  Yrs Completed

Did You Graduate?

Degree or Diploma

Graduate

 

 

 

College

 

 

 

 

Business/ Trade/ Technical

 

 

 

High School

 

 

 

 

Professional License, Registration, Certificate Or Permit

(Where Applicable)

Type: 

Number:

Issued By:

Expiration Date: 

OFFICE USE/Verified By/Date: 

  

Technical Skills: List experience, responsibilities, skills, volunteer work, etc. that pertain to the position for which you are applying

   

Person To Be Notified In Case Of Emergency

Name 

Relationship

Address (include full street address, city, state & zip)

Telephone

( )

  

References: Please list two (2) references (not relatives):

Name 

  

Relationship

 

Address (include full street address, city, state & zip)

  

Telephone

 

( )

Name 

  

Relationship

 

Address (include full street address, city, state & zip)

  

Telephone

 

( )

DECLARATION: I declare that all statements contained in this application are true and correct, to the best of my knowledge, and I authorize Fly By Night Publishing to make any inquiry to determine my suitability for employment, with the understanding that any misrepresentations or omissions made herein will be just and due cause for my discharge from employment regardless of when such misrepresentation may be discovered.

I agree to submit to any medical procedures as required by Fly By Night Publishing and any applicable regulations.  Furthermore I understand and confirm that neither this application nor my being accepted for employment at Fly By Night Publishing  will be interpreted by me to be a contract of employment for any particular length of time.  I understand that I may terminate my employment at any time for any reason and that Fly By Night Publishing reserves the same right.

Type Name Of Signature Of Individual Who Will Sign This Upon Hiring

Date

 

     
Please do not fill out anything below this point as it is for office use only:

Hired to Start:

  

Position:

 
 

Shift

  

Wage Rate

  

Floor

  
 

Full-Time

£ Part-Time

£ Temporary

£ Registry/Stand-by

£ Modified Full-Time

£ Limited Part-Time

    
     
 

Department Head / Supervisor Signature

Date

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