HR CCV

Application Data

Programs, services, and employment are equally available to everyone. Please inform the Human Resources Department if you require reasonable accommodation for the application or interview.

How Were You Referred To Us

Position Applied For

Full Name

Address

City

State

Zip

Phone

Mobile / Page / Other

Date Available to Start

Social Security #

Salary Requirement

If you are under 18 and we require a work permit, can you furnish one?:

If no, please explain

Have You Ever Worked For This Company?

If Yes, When?

Are You A Citizen Of The United States?

If Not, Are You Legally Allowed To Work In The United States?

Type Of Employment Desired

Full-Time

Part-Time

Temporary

Seasonal

Have you ever pleaded “guilty,” “no contest,” or been convicted of a crime?

If Yes give dates and details

Answering “yes” to these question does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be considered.

Driver’s license number if applicable to position

Driver State

Summarize your special skills or qualifications

Previous employment (begin with most recent position)

Employment 1

Dates Of Employment Form 1

Dates Of Employment To 1

Positions Held 1

Firm 1

Address 1

Phone 1

Supervisor 1

Title 1

Responsibilities 1

Starting Salary And Title 1

Ending Salary And Title 1

Reason For Leaving 1

May We Contact This Employer For A Reference 1

Employment 2

Dates Of Employment Form 2

Dates Of Employment To 2

Positions Held 2

Firm 2

Address 2

Phone 2

Supervisor 2

Title 2

Responsibilities 2

Starting Salary And Title 2

Ending Salary And Title 2

Reason For Leaving 2

May We Contact This Employer For A Reference 2

Employment 3

Dates Of Employment Form 3

Dates Of Employment To 3

Positions Held 3

Firm 3

Address 3

Phone 3

Supervisor 3

Title 3

Responsibilities 3

Starting Salary And Title 3

Ending Salary And Title 3

Reason For Leaving 3

May We Contact This Employer For A Reference 3

I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of personal, employment, educational, financial, and other related matters as may be necessary for an employment decision.

I herby release employers schools or individuals from all liability when responding to inquiries in connection with my application.

In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge.

References

List three (3) references that are not related to you by blood or marriage who can comment on your education or work experience:

Reference 1

Reference Full Name 1

Reference Complete Home Address 1

Reference Occupation Office 1

Reference Telephone Number 1

Reference 2

Reference Full Name 2

Reference Complete Home Address 2

Reference Occupation Office 2

Reference Telephone Number 2

Reference 3

Reference Full Name 3

Reference Complete Home Address 3

Reference Occupation Office 3

Reference Telephone Number 3

Have You Served In The Military?

Wich Branch?

Served From

Served To

Do You Any Military Commitment?

If Yes Explain

If you are claiming preference under the Veterans’ Employment Preference Act or Handicapped Persons’ Employment Preference Act, complete the following.

Veteran’s Employment Preference provides the addition of 5 percentage points or 10 percentage points to the applicant’s score when a numerically scored selection procedure is used. To claim Veteran’s Employment Preference you must be a U.S. Citizen and (check one of the boxes below)

A veteran separated under honorable conditions.

A disabled veteran separated under honorable conditions.

The spouse of a disabled veteran if the veteran’s disability prevents him/her from working.

The unremarried surviving spouse of a veteran or disabled veteran.

The mother of a veteran, IF THE VETERAN lost his/her life under honorable conditions while serving in the Armed Forces, OR has a service-connected, permanent, and total disability.

You may claim Handicapped Persons’ Employment Preference as (check one the boxes below)

A handicapped person certified by PHHS, or;

The spouse of a totally (100%) disabled person certified by PHHS, and reside continuously in Montana for at least one year immediately before applying for employment.

DD-214

PHHS Certification

Other File (CV, Cover Letter, Letter of Recommendation, etc.)

Employment Application