COMPANY OR EMPLOYER NAME:
(Mouse over for instructions, replace with employer name)
Position applying for:

EMPLOYEE INFORMATION
Name:
Last	First	Middle
Telephone:	Email:	Alternate telephone:
Address:
Are you able to perform the essential functions of	If necessary for the job, I am able to:
the position with or without accommodations?
Work overtime?	Yes	No
Yes	No
Provide a valid Alaska Driver's License?	Yes	No
If necessary for the job are you older than:
If so, fill out the following:	Issuing state:
14	15	16	(Check one)
Type:
18	19	21
Endorsement(s):	Hazardous Material	Passengers
I am legally eligible for employment in the U.S.?
Tankers	Tank with Hazardous Materials
Yes	No
School Bus	Double/Triple trailers
I am seeking a permanent position:	Yes No	Work the following shifts: (check all that apply)
I will be able to report to work
Any	Day	Night	Swing	Rotating
days after being notified I am hired.
Split	Graveyard	Other:
EMPLOYMENT HISTORY
List most recent employment first. Include summer or temporary jobs. List all experience or employers related to this job here or on an extra sheet of paper. No more than 10 years history recommended. If possible, limit application to 2 pages, as it will expand with typing.
Employer name and address:	Position title/duties, skills:

Start date:

End date:

Reason for leaving:

Pay:	$
Per:	Supervisor:	Telephone:
Employer name and address:	Position title/duties, skills:

Start date:

End date:

Reason for leaving:

Pay:	$
Per:	Supervisor:	Telephone:
Employer name and address:	Position title/duties, skills:

Start date:

End date:

Reason for leaving:

Pay:	$
Per:	Supervisor:	Telephone:
Employer name and address:	Position title/duties, skills:

Start date:

End date:

Reason for leaving:

Pay:	$
Per:	Supervisor:	Telephone:
Summarize other employment related to this job:
EDUCATION

Institution name

Years
completed

Field of study

Graduate

or degree

High school

College/university

Business/technical

Additional

MILITARY
Are you a veteran?	Yes	No
Duty/specialized training:
SKILLS & QUALIFICATIONS
Other qualifications such as special skills, abilities or honors that should be considered:
Types of computers, software, and other equipment you are qualified to operate or repair:
Professional licenses, certifications or registrations:
Additional skills, including supervision skills, other languages or information regarding the career/occupation you wish to bring to the employer’s attention:
Typing speed:	per minute
REFERENCES
List two personal references who are not relatives or former supervisors.
Name	Address	Telephone	Occupation	Years known
Name	Address	Telephone	Occupation	Years known
CONTACT
In case of accident or illness, please contact: Name:	Daytime phone:
Address:	Relationship:
INFORMATION TO THE APPLICANT
As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references.

If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms. I understand and agree to the information shown above.
(Type date here, then Tab for spellcheck)
Signature of Applicant	Date
Equal Employment Opportunity: While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment.

Developed at employer request by the Alaska Department of Labor & Workforce Development, Employment Security Division.

Rev. 11/2010	Employment Application	Page 1 of 2

Employment
Application

beuckca

2010-09-13

State of Alaska