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Coalfield CAP Employment Application
Personal Information
Social Security Number*

E-Mail:

First Name:*

Middle Initial

Last Name:*

Address Line 1:*

Address Line 2:

City:*

State:*

Zip Code:*

Home Phone:

Cell Phone:

Driver’s license number*

If under 18 can you Provide work Permit

Work Preference
Date Available*

Postion Applied For:

Desired salary range

Employment Requested:*
Full Time Part Time Temporary Any Available 

Education
High School Name/Location:

Diploma Received:*
Diploma
Equivalency
None

College Name/Location:

Degree Earned:

How many years attended

Major/Minor:

College Name/Location:

Degree Earned:

How many years attended

Major/Minor:

Employment History
Name Of Employer:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Employed From:

Employed To:

Employer Phone:

Ending Salary

Job Title:

Supervisor Name:

Reason For Leaving:

What did you like most about your position

What were the things you liked least about the position

Name Of Employer:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Employed From:

Employed To:

Employer Phone:

Ending Salary

Job Title:

Supervisor Name:

Reason For Leaving:

What did you like most about your position

What were the things you liked least about the position

Name Of Employer:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Employed From:

Employed To:

Employer Phone:

Ending Salary

Job Title:

Supervisor Name:

Reason For Leaving:

What did you like most about your position

What were the things you liked least about the position

Skills and Qualifications
Any special training, skills, licenses and/or certificates that you might have

Word Proccessing

Spreadsheet

Presentations

Email / Internet

Professional References
Please list three references that have knowledge of your professional experience.
Reference Name:

Address:

Occupation:

Phone:

Reference Name:

Address:

Occupation:

Phone:

Reference Name:

Address:

Occupation:

Phone:

Background
Have you ever pled `Guilty` or `No Contest` to, or been convicted of a crime?
*
Yes
No

If yes, Please Provide Date(s) and details.

ARE YOU A U.S. CITIZEN OR ARE YOU LEGALLY AUTHORIZED TO WORK IN THE U.S.?
*
Yes
No

Applicant Statement
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.
I expressly authorize, without reservation the employer, its representatives, employees or agents to contact obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other person, corporations or organizations for furnishing such information about me.
I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.
I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.
If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period of definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.
I also understand that if I am hired. I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard.
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient to cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.
*
I Certify that I have read, fully understand and accept all terms

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