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(904) 296-2020

Equal access to programs, services and employment is available to all persons. Those applicants requiring accommodations to the application and/or interview process should contact a representative of the Personnel Department.

Name:
Last:

First:

Middle:

Address:
Street:  City: 
State:   Zip code: 

Telephone: 

Please do not provide your SSN online. We will collect this information in person or over the phone.

Have you ever been employed here before?    

Are you legally eligible for employment in this country?   

(Proof of U.S. citizenship or immigration status will be required upon employment.)

Date available for work 

Type of employment desired   

Do you have your own car/truck?   Is this your transportation?   

Driver’s license number: 

Expires: 

State:

Have you been convicted of a felony in the last seven (7) years?   

(Such conviction may be relevant if job related, but does not bar you from employment.)

If yes, please explain


Employment History

List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience.

From to
Employer
Job Title
Telephone
Address/Street

City
State
Zip code
Immediate Supervisor and Title 
Reason for leaving
Hourly Rate/Salary
Start $   per  
Final $   per  
 
Summarize the nature of work performed and job responsibilities

 

From to
Employer
Job Title
Telephone
Address/Street

City
State
Zip code
Immediate Supervisor and Title 
Reason for leaving
Hourly Rate/Salary
Start $   per  
Final $   per  
 
Summarize the nature of work performed and job responsibilities

 

From to
Employer
Job Title
Telephone
Address/Street

City
State
Zip code
Immediate Supervisor and Title 
Reason for leaving
Hourly Rate/Salary
Start $   per  
Final $   per  
 
Summarize the nature of work performed and job responsibilities

 

From to
Employer
Job Title
Telephone
Address/Street

City
State
Zip code
Immediate Supervisor and Title 
Reason for leaving
Hourly Rate/Salary
Start $   per  
Final $   per  
 
Summarize the nature of work performed and job responsibilities

 

Summarize any training, skills, licenses, certificates and/or characteristics of yourself that may qualify you as being able to perform job-related functions for the position which you are applying

Educational Background (if job-related)

High School


College


Other

 

References

Name Telephone (with area code) Years Known

 

It is understood and agreed upon that any misinterpretation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed.

I give the employer the right to investigate all references and to secure additional information about me, if job-related. I hereby release from liability the employer and its representatives for seeking such information, and all other persons, corporations or organizations for furnishing such information.

The employer is an Equal Opportunity Employer.

The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary.

I understand it is this company’s policy not to refuse to hire a qualified individual with a disability because of this person’s need for accommodation that would be required by the ADA.