Form Ga - Employment Application Form
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1
2EMPLOYMENT APPLICATION
PARTICIPANT’S NAME: ______________________________
PERSONAL INFORMATION:
APPLICANT’S NAME:
DATE: ________________________
STREET ADDRESS: ___________ __________________
CITY: __________ ______________
STATE:
ZIP:
SOCIAL SECURITY #:
HOME PHONE NUMBER:
OTHER:
E-MAIL ADDRESS:
____________________
_
EMPLOYMENT ELIGIBILITY:
To be employed with the State of Georgia, you must meet certain State and Federal employment eligibility
requirements. These include, but are not limited to, United States citizenship or authorization to work in this
country, and no felony convictions.
Are you interested in serving as a (check all that apply):
Full-time employee?
Part-time employee?
Backup employee?
Are you currently employed:
___YES
NO
Date available for employment:
How many hours a week can you work?
Are you 18 years of age or older?
___YES
NO
Are you a United States citizen?
___YES
NO
Are you an alien authorized to work in the United States? ___YES
NO
GEORGIA LICENSES AND CERTIFICATIONS:
Do you have a valid driver's license?
___YES
NO
Do you have current First Aid Certification*?
___YES
NO
if yes, expiration date: ______________
Do you have current CPR Certification*?
___YES
NO
if yes, expiration date: ______________
Do you have Nurse Aide Certification?
___YES
NO
if yes, expiration date: ______________
Please list any other professional certifications:
* If hired, you must provide a copy of your current CPR card and First Aid card to your employer.
EDUCATION:
High School Graduate or equivalent (GED)? ___YES
NO
Vocational/Business School?
___YES
NO
if yes, field of study:
# of months:
completion date:
College? ___YES
NO
College Graduate?
___YES
NO
if yes, degree:
completion date:
LIST THREE PERSONAL REFERENCES:
(Name)
(Address)
(Phone Number)
(Name)
(Address)
(Phone Number)
(Name)
(Address)
(Phone Number)
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Parent category: Business