Employment Application We consider applications for all positions without regard to race, color, religion, creed, sex, national origin, disability, sexual orientation, citizenship status, or any other legally protected status. Starpoint Application for Employment Step 1 of 4 25% Program Applied For* Adult Services - Cañon City Adult Services - Salida Children Services - Cañon City Position(s) Applied For Date of Application MM slash DD slash YYYY How did you learn about us? Advertisement Employment Agency Relative Friend Inquiry Other Other Name First Middle Last Address Street Address City State / Province / Region ZIP / Postal Code PhoneEmail Best time to contact you at home: If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No I am over 18 years of age Have you ever filed an application with us before? Yes No If yes, give date: Have you ever been employed with us before? Yes No If yes, give date: Do any of your friends or relatives, other than spouse, work here? Yes No Are you currently employed? Yes No May we contact your present employer? Yes No Not currently employed Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes No Proof of citizenship or immigration status will be required upon employment. Date available for work: MM slash DD slash YYYY What is your desired salary range? Are you available to work: Full-Time Part-Time Temporary Please indicate 1, 2, or 3 shifts: 1 Shift 2 Shifts 3 Shifts Please indicate when: Select All Mornings Afternoons Evenings Please indicate dates available: Are you currently on "lay-off" status and subject to recall? Yes No Can you travel if a job requires it? Yes No EDUCATIONHigh School:Name & Address of School(s) Course of Study Number of Years CompletedDiploma/Degree Undergraduate College:Name & Address of School(s) Course of Study Number of Years CompletedDiploma/Degree Graduate Professional:Name & Address of School(s) Course of Study Number of Years CompletedDiploma/Degree Other/Additional Schooling:Describe any specialized training, apprenticeship, skills, and extra-curricular activities.Describe any job-related training received in the United States military. EMPLOYMENT EXPERIENCEStart with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status. Employer Address Street Address City State / Province / Region ZIP / Postal Code PhoneJob Title Supervisor Reason for Leaving Dates Employed Hourly Rate/Salary Work PerformedEmployer Address Street Address City State / Province / Region ZIP / Postal Code PhoneJob Title Supervisor Reason for Leaving Dates Employed Hourly Rate/Salary Work PerformedEmployer Address Street Address City State / Province / Region ZIP / Postal Code PhoneJob Title Supervisor Reason for Leaving Dates Employed Hourly Rate/Salary Work PerformedEmployer Address Street Address City State / Province / Region ZIP / Postal Code PhoneJob Title Supervisor Reason for Leaving Dates Employed Hourly Rate/Salary Work PerformedList professional, trade, business, or civic activities and offices held.You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability, or other protected status. ADDITIONAL INFORMATIONOther QualificationsSummarize special job-related skills and qualifications acquired from employment or other experience.Check Skills/Equipment Operated: Terminal PC/MAC Typewriter Spreadsheet Word Processing Shorthand Other Other (List) Production/Mobile Machinery (List) How many words per minute can you type? State any additional information you feel may be helpful to us in considering your application.Can you perform essential functions of the job, for which you are applying, either with or without a reasonable accommodation?Note to Applicants: Do NOT answer this questions unless you have been informed about the requirements of the job for which you are applying. Yes No ReferencesName First Last PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Name First Last PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Name First Last PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Applicant's StatementI certify that answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship wit this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. SignatureDate MM slash DD slash YYYY 5 + 3 =*