DemorInstitute

General Information:

First Name*

Last Name*

Address (Mailing Address):*

Address Line 1*

Country*

State*

City*

Zip Code*

Cell*

Alternate Cell

Email*

Are you legally entitled to work in the U. S.?*

Yes

No

Position

Position Or Type Of Employment Desired

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

Yes

No

Will Accept*

Part-Time

Full-Time

Temporary

Shift*

Day

Swing

Rotating

Evening

Salary Desired*

Date Available*

Identification

Please provide photo identification, such as a driver license*

Car/vehicle registration number

Alternative Form of ID

Education & Training

High School Graduate Or General education (GED) Test Passed?*

Yes

No

College*

Yes

No

Business School

Yes

No

Military

Yes

No

Occupational License, Certification or Registration

Where Issued

Expiration Date

Languages Read, Written or Spoken Fluently Other Than English

Veteran Information(Most recent)

Branch of Service

Date of Entry

Date of Discharge

Special Skills*

List all pertinent skills and equipment that you can operate

Reference

(List relative or friends who have known you for 5 or more years)

First Name:

Last Name:

Email Address

Telephone Number

Address

Relative or Friend

From (Month/Year)

To (Month/Year)

First Name(2):

Last Name(2):

Email Address(2)

Telephone Number(2)

Address(2)

Relative or Friend(2)

From (Month/Year)(2)

To (Month/Year)(2)

First Name(3):

Last Name(3):

Email Address(3)

Telephone Number(3)

Address(3)

Relative or Friend(3)

From (Month/Year)(3)

To (Month/Year)(3)

First Name(4):

Last Name(4):

Email Address(4)

Telephone Number(4)

Address(4)

Relative or Friend(4)

From (Month/Year)(4)

To (Month/Year)(4)

First Name(5):

Last Name(5):

Email Address(5)

Telephone Number(5)

Address(5)

Relative or Friend(5)

From (Month/Year)(5)

To (Month/Year)(5)

Reference

(Most Recent First) (Include voluntary work and military experience)

Employer*

Telephone Number*

Address*

Job Title

Number Employees Supervised

Hours Per Week

From (Month/Year)

To (Month/Year)

Last Salary

Supervisor

Specific Duties

Reason For Leaving

May We Contact This Employer?

Yes

No

Have you ever been in a lawsuit with an employer? If so, for what reason?

Yes

No

Have you ever been convicted of a crime? If so please explain

Yes

No

Signature of Applicant*

I certify the information in this application is true, correct and complete. I understand that, if employed, false statements reported on this application may be sufficient cause for dismissal and or prosecution. DHST Incorporated is an equal opportunity employer and provider of employment and training services.

General Information:

Are you legally entitled to work in the U. S.?*

Position

Position Or Type Of Employment Desired

Identification

Education & Training

Veteran Information(Most recent)

Special Skills*

Reference

(List relative or friends who have known you for 5 or more years)

Reference

(Most Recent First) (Include voluntary work and military experience)

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