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Rev. 7/17/03 Word-Staff Forms
References & Eligibility Information
Please list 2 references, not including relatives or former supervisors.
Name: ______________________________________ Occupation: ______________________________
Address: ____________________________________________________ Telephone: _______________
Name: ______________________________________ Occupation: ______________________________
Address: ____________________________________________________ Telephone: _______________
Name: ______________________________________ Occupation: ______________________________
Address: ____________________________________________________ Telephone: _______________
Name: ______________________________________ Occupation: ______________________________
Address: ____________________________________________________ Telephone: _______________
Are you authorized to work in the United States? [ ] Yes [ ] No
Have you ever illegally used drugs in the last two years/ [ ] Yes [ ] No
Have you ever been convicted of a crime? [ ] Yes [ ] No
If yes, did it result in a deferred adjudication? [ ] Yes [ ] No
What court did the conviction occur? __________________________________________
I authorize the prospective employer to inquire as to my record of any or all persons and of my former
employers. ___________ (initial)
In the event of my employment with this organization: I agree to comply with the rules and regulations
governing my employment, including but not limited to: A criminal history check; TB test, required
training and the requirements regarding age and education. __________ (initial)
In the event I should terminate my employment, I agree to file my resignation in writing TWO WEEKS
prior to the date effective. I understand that by not filing my resignation in writing tow weeks prior to
termination I will not be eligible for re-hire. ______________ (initial)
APPLICANT’S SIGNATURE __________________________ DATE _______________
------------------------------DO NOT WRITE IN THE SPACE BELOW----------------------------
Date to start work: _________________ Temporary: _________________ Program: ________________
Position: _____________________________________________________________________________
Remarks: _____________________________________________________________________________
Hourly Wage: ________________________________ Site: ____________________________________