Employment Application

APPLICANT INFORMATION

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Last Name

First Name & Middle Initial

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

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Phone 1

Phone 2

Email

Confirm Email

Date of Birth

Are you eligible to work in the US?

Have you ever been terminated from employment or asked to resign by an employer?

If yes, please provide company name and details.

POSITION AVAILABLE

How did you learn of the position available?

Are you able to perform the essential functions of this job for which you are applying, with or without a reasonable accommodation?

Start Date

Available Start Date

Salary Desired

EDUCATION

Education / High School

High School

Location

Years Attended

Major & Degree Earned

Education / College

College or University

Location

Years Attended

Major & Degree Earned

Education / College 2

College or University

Location

Years Attended

Major & Degree Earned

Education / Trade School

Trade, Business, or Correspondence School

Location

Years Attended

Major & Degree Earned

Other / Applicable Training / Skills / Proficiencies

EMPLOYMENT HISTORY

List most recent job first and work backwards in time.

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Employer Name

Job Title

Start Date

End Date

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Address

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor Name

Phone

Email

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Starting Rate of Pay

Ending Rate of Pay

May we contact?

Summarize the nature of work performed and job responsibilities:

Reason for leaving:

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Employer Name

Job Title

Start Date

End Date

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Address

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor Name

Phone

Email

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Starting Rate of Pay

Ending Rate of Pay

May we contact?

Summarize the nature of work performed and job responsibilities:

Reason for leaving:

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Employer Name

Job Title

Start Date

End Date

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Address

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor Name

Phone

Email

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Starting Rate of Pay

Ending Rate of Pay

May we contact?

Summarize the nature of work performed and job responsibilities:

Reason for leaving:

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Employer Name

Job Title

Start Date

End Date

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Address

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor Name

Phone

Email

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Starting Rate of Pay

Ending Rate of Pay

May we contact?

Summarize the nature of work performed and job responsibilities:

Reason for leaving:

REFERENCES

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Name

Company

Address, Phone, Email

Number of Years Acquainted

Name

Company

Address, Phone, Email

Number of Years Acquainted

Name

Company

Address, Phone, Email

Number of Years Acquainted

Name

Company

Address, Phone, Email

Number of Years Acquainted

RESUME

Upload Resume (if available)

Click or drag a file to this area to upload.

Please upload a .pdf resume.

DISCLAIMER / AUTHORIZATION / LEGAL STATEMENT

The Northwest Georgia Regional Commission (NWGRC) is an equal opportunity employer. NWGRC does not discriminate in employment with regard to race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service or any other characteristic protected by law.

PLEASE READ CAREFULLY BEFORE SIGNING

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the NWGRC to hire me. If I am hired, I understand that either the NWGRC or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the NWGRC has the authority to make any assurance to the contrary.

I attest with my signature below that I have given to the NWGRC true and complete information on this application. No requested information has been concealed. I authorize the NWGRC to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.

Signature Disclaimer

I understand that applications submitted electronically are not valid unless I enter my name in the signature field below and such action shall constitute an electronic signature.

Signature Block

Signature

Date

THIS APPLICATION IS VALID ONLY FOR 60 DAYS FROM THE DATE ABOVE

APPLICANT INFORMATION

POSITION AVAILABLE

EDUCATION

EMPLOYMENT HISTORY

REFERENCES

RESUME

DISCLAIMER / AUTHORIZATION / LEGAL STATEMENT

PLEASE READ CAREFULLY BEFORE SIGNING

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