Employment Application Name* First Last Address* 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 PhoneEmail* Social Security Number: Position(s) Applied for: Salary Desired Are you applying for: Full Time Part Time Temporary Date available for work: Would you consider working any shift? Yes No Weekend & Holidays? Yes No On Call? Yes No Shift Preference Day Evenings Weekends How were you referred to Lower Sioux Health and Human Services?Do you have any relatives or friends employed at Lower Sioux Health and Human Services? Yes No If yes, which department? Have you ever filed an application with us before? Yes No If yes, when? Are you a U.S. Citizen or an alien legally authorized to work in the United States? Yes No EducationHigh SchoolSchool Name and LocationYears CompletedDid you Graduate?Diploma / Degree Undergraduate College/UniversitySchool Name and LocationCourse of StudyYears CompletedDid you Graduate?Diploma / Degree Graduate/ProfessionalSchool Name and LocationCourse of StudyYears CompletedDid you Graduate?Diploma / Degree Other business college, other special courses (Include special military training, post graduate and nursing)Area of specialization or other interestList health care, business or industrial equipment operatedProfessional License and/or CertificationsAre you currently: Registered Licensed Certified Eligible for: Registered Licensed Certified If registered, licensed or certified:TypeState IssuedDateNo. Employment Experience (most recent first)Employer 1Date Employed From/To Name of Employer Employer Address and Phone NumberSupervisor Title DutiesHourly Rate/Salary Reason for LeavingMay we contact this employer?YesNoIf no, please explain:Employer 2Date Employed From/To Name of Employer Employer Address and Phone NumberSupervisor Title DutiesHourly Rate/Salary Reason for LeavingMay we contact this employer?YesNoIf no, please explain:Employer 3Date Employed From/To Name of Employer Employer Address and Phone NumberSupervisor Title DutiesHourly Rate/Salary Reason for LeavingMay we contact this employer?YesNoIf no, please explain:Did you serve in the U.S. Armed Services?YesNoIf yes, what branch? Have you volunteered your time or services?YesNoIf yes, where? Briefly describe duties and skills acquired through volunteer service (include dates):References(List at least 3 references who are not relatives or employers)NameRelationship/TitleAddressPhone References #2NameRelationship/TitleAddressPhone References #3NameRelationship/TitleAddressPhone 92574
