| * Full Name: |
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| * Social Security Number: |
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| * Address: |
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| * City: |
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| * State: |
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| * Zip Code: |
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| * Home Phone: |
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| Other Phone: |
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| Email Address: |
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| * Position(s) Applying For: |
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| * Date Available For Employment: |
Wednesday, October 28, 2009   |
| Will You Accept |
| * Full-Time Employment? |
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| * Part-Time Employment? |
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| * Temporary Employment? |
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| * Have you previously held an employment position with the Rock Island Tri-County Consortium; Private Industry Council, Inc. of Rock Island, Henry and Mercer Counties, Illinois; or former CETA Administrative Offices in Rock Island, Henry or Mercer Counties? |
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| If Yes, Please Provide |
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| Position Title(s) |
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| Employed From: |
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| To: |
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| * Are you Legally Authorized to Work in the United States? |
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| If Alien, Registraion Number: |
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| VISA Type: |
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| * Have you been Convicted of a Felony Offense? |
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| (Conviction will not necessarily disqualify applicant from employment) |
| If Yes, Give a Detailed Statement: |
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| List Relative(s) and Their Relationship to You Who Is/Are Currently Employed with the Rock Island Tri-County Consortium |
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| * Do You Have a Valid Driver's License? |
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| * If Needed, Do You Have Access to an Automobile for Work Use? |
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| * Can You Travel If a Job Requires It? |
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| Education and Training |
| * High School Diploma / GED Certificate: |
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| List Other Relevant Training (Seminars, Workshops, Etc.) Completed: |
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| License/Certification Registration |
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| Section C |
| Military Service |
| * Were You in the U.S. Armed Forces? |
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| If Yes, What Branch? |
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| Dates of Duty: |
From: to |
| List Duties in the Service, Including Specialt Training, Which are Related to the Positions for Which You are Applying: |
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| ANSWERING THIS SECTION IS OPTIONAL |
| If you belong to any professional, trade, business, civic or service groups and wish credit to be given you for duties performed for these groups, complete this section. You may exclude memberships which would reveal sex, race, religion, natural origin, age, ancestry, disability or other protected status. |
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| ANSWERING THIS SECTION IS OPTIONAL |
| Do you fluently speak or write any foreign language? |
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| If Yes, which? |
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| (Proof of language proficiency may be required prior to date of hire.) |
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STATEMENT & AUTHORITY TO RELEASE INFORMATION
PLEASE READ THIS STATEMENT CAREFULLY BEFORE SUBMITTING THIS APPLICATION
I understand that if I am employed, any misrepresentation or omission of material facts on this application is sufficient cause for dismissal. The agency, in considering my application for employment, may verify the information set forth on this application and obtain additional information relating to my background. I authroize all persons, schools, companies, corporations, credit bureaus, law enforcement agencies and doctors to supply any information concerning my background. |
| * I agree: |
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ALL APPLICANTS MUST E-MAIL A RESUME TO CAROL SLAVISH AT: CSLAVISH@PJTP.ORG
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