EMPLOYMENT APPLICATION FORM PLEASE DO NOT REAPPLY WITHIN 6 MONTHS OF THE DATE OF YOUR LAST APPLICATION Name * Required First Last Address * Required Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email * Required Phone - Home * RequiredPhone - Work * RequiredMay we contact you at work? * Required Yes No Position(s) Desired, In Order Of Preference * RequiredHourly wage/Annual salary desired * RequiredDate available for work * Required MM slash DD slash YYYY Age: Are you at least 18 year old? * Required Yes No Age: Are you at least 21 year old? * Required Yes No In order to permit a check of your work and education records, should we be made aware of any change of name or assumed name that you previously used? * Required Yes No Identify name and date * RequiredNameDate Have you ever been employed by Elmbrook Humane Society before? * Required Yes No Where? * RequiredWhen? * Required MM slash DD slash YYYY Final Position * RequiredReason for leaving * RequiredDo you have any relatives who either work or have previously worked for Elmbrook Humane Society? * Required Yes No Please specify * RequiredHave you previously applied for employment here? * Required Yes No When? * Required MM slash DD slash YYYY Work ExperienceEmployer/Company * RequiredAddress * Required Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number * RequiredStarting job title * RequiredStarting Salary/Wage * RequiredLast Job Title * RequiredFinal Salary/Wage * RequiredDate Employed From * Required MM slash DD slash YYYY Currently Employed? * Required Yes No Date Employed To * Required MM slash DD slash YYYY Immediate Supervisor * RequiredDuties * RequiredReason for Leaving * Required * Required Voluntary Involuntary May we contact this employer? * Required Yes No Add More Experience 1 Add More Experience Work Experience 2Employer/Company * RequiredAddress * Required Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone numberStarting job title * RequiredStarting Salary/Wage * RequiredLast Job Title * RequiredFinal Salary/Wage * RequiredDate Employed From * Required MM slash DD slash YYYY Date Employed To * Required MM slash DD slash YYYY Immediate Supervisor * RequiredDuties * RequiredReason for Leaving * Required * Required Voluntary Involuntary May we contact this employer? * Required Yes No Add More Experience 2 Add More Experience Work Experience 3Employer/Company * RequiredAddress * Required Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number * RequiredStarting job title * RequiredStarting Salary/Wage * RequiredLast Job Title * RequiredFinal Salary/Wage * RequiredDate Employed From * Required MM slash DD slash YYYY Date Employed To * Required MM slash DD slash YYYY Immediate Supervisor * RequiredDuties * RequiredReason for Leaving * Required * Required Voluntary Involuntary May we contact this employer? * Required Yes No Education and TrainingHigh School * RequiredClick "+" to add more high schoolsName of SchoolCityStateNumber of years completedGraduated (Yes or No)Major or Course Type College * RequiredClick "+" to add more collegesName of SchoolCityStateNumber of years completedGraduated (Yes or No)Major or Course Type Additional Training * RequiredClick "+" to add more additional trainingName of SchoolCityStateNumber of years completedGraduated (Yes or No)Major or Course Type Clerical * RequiredCheck if you have experience in the following: Data Entry Reception Word Processing Programs Spreadsheet Programs Switchboard Typing What word processing programs do you use? * RequiredWhat spread sheet programs do you use? * RequiredTyping Speed (words per minute) * RequiredPlease enter a number from 0 to 500.Animal Welfare or Veterinary Clinic ExperienceAnimal Welfare or Veterinary Clinic Experience None Animal Welfare or Veterinary Clinic Experience * Required Customer Service Cashiering Animal Handling Grooming Kennel Cleaning Animal Behavior Maintenance/Repair Vet Technician Other Others * RequiredPermission to WorkAre you legally authorized to work in the United States? * Required Yes No Conviction RecordHave you been convicted of a crime within the last 5 years? * Required Yes No (An affirmative answer will not necessarily disqualify you from employment.)Details of Crime * RequiredDate of Crime * Required MM slash DD slash YYYY Physical Limitation - Emergency Notification DesignationAre you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation? * Required Yes No Please describe any accommodations required. * RequiredPlease describe any accommodations required.Person to notify in case of emergency: * RequiredPhone * RequiredAddress * Required Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Referral SourceCheck One * Required EBHS Website Employee Referral Newspaper ads School/College Walk-In Applicant Other Name * RequiredIndicate Other Source * RequiredApplicant's StatementConsent * Required I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that any falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. * RequiredConsent * Required I authorize a thorough investigation of my past employment and activities, agree to cooperate in such investigation, and release from all liability or responsibility all persons and corporations requesting or supplying Information, I further authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the job for which I am being considered or any future job in the event I am hired. * RequiredConsent * Required I hereby agree to submit to any lawful drug, integrity, or skills testing that may be required as a condition of employment or continued employment and understand that unless otherwise prohibited by law, refusal to submit to such testing during the course of my employment may result in disciplinary action, up to and including discharge. I further agree to submit to search of my person or of any locker or work area that may be assigned to me, and I hereby waive all claims for damages on account of such examination. * RequiredConsent * Required I understand that this application is valid for 6 months; I will reapply after that time if I am still interested in employment. I also understand that my employment is terminable-at-will, and that this application is not, and is not intended to be, a contract for continued employment. * RequiredSignature * Required Δ