Employment Application

Contact Information

First Name

Last Name

Address 1

City

State

Postal Code

How should we contact you ?

Phone Number

Mobile Phone

Email Address

Information Requested

How long have you lived at the above address?

Are you 18 years of age or older?

Yes

Identification: Drivers License # and State of Issue

Job Position

Position applied for?

Number of hours of work desired?

Are you looking for seasonal work?

Yes

Salary, Rate of Pay and Availability

Rate of pay expected:

Specific days and hours available:

If hired, on what date will you be available to start?

Are you currently employed?

Yes

If so, may we contact your employer?

Yes

Have you worked with us before?

Yes

If yes, where and when?

Position/Department:

Range of Dates:

Were you referred to Bentwater by an individual currently employed at BYCC? If so, please list their names.

Have you ever been fired, asked to resign or been subject to disciplinary action in your current or previous employment?

Yes

If yes, describe in full:

Have you ever been convicted of a felony?

Yes

If yes, describe in full:

Have you ever been counseled or disciplined for cash handling discrepancies?

Yes

Have you ever been counseled for being late to school or work?

Yes

Are you able to perform all the essential functions of the job for which you are applying, with or without reasonable accommodations?

Yes

If hired, can you provide proof of eligibility to work in the United States prior to starting work?

Yes

Education

High School

Name of School

City & State

Number of Years Attended

Graduate

Yes

College

Name of School

City & State

Number of Years Attended

Course or Major

Graduate

Yes

Other Education (Please describe)

Most Recent Employer

Employer's Name

Employer's Phone Number

Name of Immediate Supervisor

City/State

Dates of Employment - To and From

Title

Duties

Starting Salary (optional)

Present/Final Salary (optional)

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

Employer 2

Employer's Name

Employer's Phone Number

Name of Immediate Supervisor

City/State

Dates of Employment - To and From

Title

Duties

Starting Salary

Present/Final Salary

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

Employer 3

Employer's Name

Employer's Phone Number

Name of Immediate Supervisor

City/State

Dates of Employment - To and From

Title

Duties

Starting Salary

Present/Final Salary

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

Employer 4

Employer's Name

Employer's Phone Number

Name of Immediate Supervisor

City/State

Dates of Employment - To and From

Title

Duties

Starting Salary

Present/Final Salary

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

If any periods of unemployment please give details on how you spent your time.

List (3) References - not related to you.

Reference #1 Name

Reference #1 Phone Number

Reference #1 Relationship

Reference #2 Name

Reference #2 Phone Number

Reference #2 Relationship

Reference #3 Name

Reference #3 Phone Number

Reference #3 Relationship

How did you hear about this position?

Please email your resume�, in PDF format, to [email protected]

* Bold Fields are Required - Required number fields will not accept 0's.