Southwest Community Services, Inc.

* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):

Yes   No

* Are you at least 18 years or older?:

Yes   No

* For driving positions: Are you at least 23 years or older?:

Yes   No

* Do you have a valid state drivers license?:

Yes   No

* Have you been convicted of more than one traffic ticket/violation in the past year?:

Yes   No

* List all traffic tickets and/or violations in the past five years::

* Have you ever been convicted of a felony or a misdemeanor which resulted in imprisonment within the last seven years? (A conviction will not necessarily result in the denial of employment):

Yes   No

If Yes, please explain:

* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:

Yes   No

If No, HR will discuss possible accommodations.:

* Have you been discharged from any employment or asked to resign? (layoffs do not need to be reported here):

Yes   No

If Yes, please explain:

* Consistent attendance and punctuality are essential requirements of every job with this agency.  Is there anything which would interfere with your regular attendance and punctuality if you were offered a job with the agency?:

Yes   No

If yes, please explain:

What is your salary requirement?:

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location	Did you Graduate? If not, how many years did you complete?	Degree Received	Subjects Studied/Major

List any other experience, skills, training or other qualifications, which you believe should be considered in evaluating your qualifications for employment.:

Give your full employment record, starting with your current or most recent employment

Employer Name & Address (1)

From/To (1)

Employer Phone (1)

Job Title (1)

Supervisor Name & Title (1)

Duties (1)

Reason for Leaving (1)

Hourly Rate / Salary (1)

From/To (2)

Employer Name & Address (2)

Employer Phone (2)

Job Title (2)

Supervisor Name & Title (2)

Duties (2)

Reason for Leaving (2)

Hourly Rate / Salary (2)

From/To (3)

Employer Name & Address (3)

Employer Phone (3)

Job Title (3)

Supervisor Name & Title (3)

Duties (3)

Reason for Leaving (3)

Hourly Rate / Salary (3)

Name	Relationship	Phone Number

The facts set forth in this application and any supplemental information is true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):
* Date: