Sample Employment Application Form
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1
2DOMESTIC VIOLENCE SHELTER & SERVICES, INC.
PO Box 1555
Wilmington, NC 28402
910.343.0703 Phone / 910.343.9388 Fax
(Application invalid without written signature and date)
We are an equal opportunity employer, dedicated to a policy of non-discrimination in recruitment, hiring,
compensation, fringe benefits, staff development, training, promotion and any other conditions of employment.
This agency does not discriminate based on race, color, religion, age, sex, national origin, political affiliation,
sexual identity, or any other non-performance factors.
Name:
Last
First
Middle
If employment or school was under a different name, indicate:
P
Permanent Address (No. & Street)
City
State
Zip Code
Tel. No. (incl. area code)
E
R
Present Address (No. & Street)
City
State
Zip Code
Tel. No. (incl. area code)
S
O
Tel. No. (incl. area code)
If not a U.S. citizen, do you have the legal right to remain permanently in the U.S.?
Yes
No
N
A
Have you ever been found guilty of, or
Position desired:
Valid Driver’s License?
Yes
No
convicted of, or plead no contest to a
L
criminal offense?
Yes
No
Access to a car while on duty?
Yes
No
List last two positions; show your most recent experience first:
Dates Employed
Title of position
Final salary
Reason for leaving
From
To
Mo.
Yr.
Mo.
Yr.
Employer’s name and address
Supervisor’s name, address and telephone number
E
M
P
Describe your primary responsibilities
L
O
Y
M
Dates Employed
Title of position
Final salary
Reason for leaving
E
From
To
N
Mo.
Yr.
Mo.
Yr.
T
Employer’s name and address
Supervisor’s name, address and telephone number
E
X
Describe your primary responsibilities
P
E
R
I
E
List additional employment experience
N
Dates employed from, to
Title of position
Name and address of employer
C
E
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Parent category: Business