Application

PERSONAL

Last Name

First Name

Middle Initial

Street Address

City

State

Zip

Email

Home Telephone

Cell Telephone

Date of Birth

Social Security # (optional)

In case of emergency, please notify:

Name

Relationship

Address

Telephone

Postion Desired

Wage Requirement

Date available to begin work

Have you ever applied at or been employed by NSPS?
Yes
No

If yes, Month and Year

Location

Type of employment desired:

Permanent: Full Time
Part Time

Temporary: Full Time
Part Time

Shift Desired: 8-4
4-12
12-8

Are you available to work:

Saturdays?
Yes
No

Sundays?
Yes
No

Are you over 18 years old?
Yes
No

Will you work overtime if asked?
Yes
No

Are you willing to travel?
Yes
No

EDUCATION

College

Name and Location of School

Course of Study

No. of Years Completed?

Did You Graduate?
Yes
No

Degree or Diploma

Business/Trade/Technical

Name and Location of School

Course of Study

No. of Years Completed?

Did You Graduate?
Yes
No

Degree or Diploma

High School

Name and Location of School

Course of Study

No. of Years Completed?

Did You Graduate?
Yes
No

Degree or Diploma

G.E.D. (if Applicable)

Name and Location of School

Course of Study

No. of Years Completed?

Did You Graduate?
Yes
No

Degree or Diploma

EMPLOYMENT

Please give accurate, complete full-time and part-time employment records. Start with your present or most recent employmer and account for your last 10 years of employment. You may include volunteer positions.

Company Name

Address

Telephone

Name of Supervisor

Dates of Employment (Month and Year, MM/YYYY) From:

To:

Hourly Pay Start:

Last:

State Job Title and Describe Your Work

Reason for Leaving

Company Name

Address

Telephone

Name of Supervisor

Dates of Employment (Month and Year, MM/YYYY) From:

To:

Hourly Pay Start:

Last:

State Job Title and Describe Your Work

Reason for Leaving

Company Name

Address

Telephone

Name of Supervisor

Dates of Employment (Month and Year, MM/YYYY) From:

To:

Hourly Pay Start:

Last:

State Job Title and Describe Your Work

Reason for Leaving

PERSONAL REFERENCES

Give the names of three responsible persons, other than relatives or former
employers, who know you well enough to give information about you.

Name

Address

Telephone

Occupation

Address

Telephone

Occupation

Name

Address

Telephone

Occupation

HISTORY

The information requested is needed for a legally permissable reason.
All information provided will be held in strictest confidence.

Sex:
Male
Female

Are you a U.S. Citizen?
Yes
No

If no, your Alien Registration No.:

Did you serve in the military?
Yes
No

If yes, what branch?

Dates of service:

Rank at Discharge:

Type of Discharge:

Do you have a DD214?
Yes
No

Are you studying at the present time?
Yes
No

If yes, what subject?

Where?

What was your previous address?

How long at present address?

How long at previous address?

Have you ever been bonded?
Yes
No

Do you have a valid permanent Driver’s License?
Yes
No

State of issue:

License Number:

Has your Driver’s License ever been revoked or suspended?
Yes
No

If yes, explain why, when, and where.

Have you ever been convicted of a crime anywhere in the U.S. or abroad including a felony, misdemeanor, motor vehicle, or summary offense, which has not been annulled, expunged or sealed by a court of law?

Yes
No

(If ‘yes’ describe the offenses for which you were convicted, the date and the place). This information will be verified.

State names of relatives and friends working for us, other than your spouse:

Do you have any physical condition which might limit your ability to perform the job for which you are applying?
Yes
No

If yes, describe this condition and how you can perform the job in spite
of it:

Identify any special training or skills you have: (languages, emergency medicine, etc.)