Employment Application

Personal

Last*

First*

Middle

Street Number*

City*

State*

Zip Code*

Email*

Home Phone

Cell Phone

Work Phone

Position Sought*

Full Time
Part Time

Date Available*

Salary Desired

Are you over 18 years old?*

No Yes

Are you legally eligible for employment in the United States?*
(If offered employment, you will be required to provide documentation to verify eligibility)
No Yes

How did you hear about this job?

Professional License or Membership

Type of License(s) Held

State

License Number

Expiration Date

Other Professional Membership

(Do not disclose membership in professional organizations that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry, age, disability, marital status, veteran status or any other protectred status.)

Skills

Excel

Google Sheets

Other (specify)

MS Word

PowerPoint

Other (specify)

Other Software Used

Other Hardware Used

Employment

Do not indicate "see resume." List last employer first, including US Military Service.

Have you ever been employed by the AMA?*
No Yes

If so, please state name used and dates of employment

May we contact your present employer?*
No Yes

If any employment was under a different name, indicate name

Employer 1

Employer

Position

Address

Telephone

Dates of employment:

From:

To:

No. of Hrs./Wk

Salary

Supervisor

Department

Duties

Reason for leaving

Employer 2

Employer

Position

Address

Telephone

Dates of employment:

From:

To:

No. of Hrs./Wk

Salary

Supervisor

Department

Duties

Reason for leaving

Employer 3

Employer

Position

Address

Telephone

Dates of employment:

From:

To:

No. of Hrs./Wk

Salary

Supervisor

Department

Duties

Reason for leaving

Explain any gaps in work history

Have you ever been discharged or asked to resign from a job?*
No Yes
If yes, explain

Professional References

Please include at least one previous employer.

Reference 1

Name

Address

Phone

Reference 2

Name

Address

Phone

Reference 3

Name

Address

Phone

Reference 4

Name

Address

Phone

You will be asked for a signature on the next page and will have the opportunity to attach additional materials, for example a cover letter and resume, on the third & last page.

Employment Application

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