APPLICATION FOR EMPLOYMENT

EQUAL OPPORTUNITY EMPLOYER

Date of Application Last Name First Name Middle Name

Address (Street Number and Name) City State Zip Code

Home Phone Mobile Phone Email Address

Availability- When are Are you 18 or older? Have you ever been employed Position Applied for:
you able to start? by ASNC before? If so, when?

Salary Requirements Job Status You Would Accept Please Indicate Your Referral Source
‫ ٱ‬Full Time ‫ ٱ‬Part Time

EDUCATION
Name Dates Attended Grad? # of Major/Minor Type of Degree
Hours Received
High School From: Yes

To: No
College From: Yes

To: No
College From: Yes

To: No
Graduate From: Yes

To: No
Trade, From: Yes
Business,
Other To: No

Relevant Workshops and Seminars Attended:

Please List Membership in any Professional, Honorary, or Technical Societies:

Do you have any of the following Red Cross or equivalent credentials? If yes, please state the expiration date.
First Aid Certificate CPR Certificate Water Safety Instructor Advanced Lifesaving
 WORK HISTORY (include volunteer experience)
Current or Last Employer: Address:

Job Title: Supervisor’s Name: Telephone Number: No. Supervised by you:

Date Employed (mo/yr) Starting Salary Ending Salary Reason for Leaving May We Contact
$ per $ per Employer?
Date Separated (mo/yr) List major duties in order of their importance in the job:

Full Time Years Months

Part Time Years Months

If PT, number of hours

worked per week:
Previous Employer: Address:

Job Title: Supervisor’s Name: Telephone Number: No. Supervised by you:

Date Employed (mo/yr) Starting Salary Ending Salary Reason for Leaving May We Contact
$ per $ per Employer?
Date Separated (mo/yr) List major duties in order of their importance in the job:

Full Time Years Months

Part Time Years Months

If PT, number of hours

worked per week:
Previous Employer: Address:

Job Title: Supervisor’s Name: Telephone Number: No. Supervised by you:

Date Employed (mo/yr) Starting Salary Ending Salary Reason for Leaving May We Contact
$ per $ per Employer?
Date Separated (mo/yr) List major duties in order of their importance in the job:

Full Time Years Months

Part Time Years Months

If PT, number of hours

worked per week:

I certify that I have given true, accurate, and complete information on this form to the best of my knowledge. In the
event confirmation is needed in connection with my work, I authorize educational institutions, associations,
registration and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I
authorize investigation of all statements made in this application and understand that false information or
documentation, or failure to disclose relevant information may be grounds for rejection of my application,
disciplinary action or dismissal if I am employed, and (or) criminal action. I further understand that dismissal upon
employment shall be mandatory if fraudulent disclosures are given to meet position qualifications (Authority: G.S.
126-30, G.S. 14-122.1).

__________________________________________________________ _____________________________
Signature of Applicant Date