APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

DATE MAY 1, 2016

NAME (LAST NAME FIRST)

SOCIAL SECURITY NO.

Kerr, Sara

On file in Human Resources

PRESENT ADDRESS

CITY

STATE

ZIP CODE

P.O. Box 226

Hardwick

VT

05843

PERMANENT ADDRESS

CITY

STATE

ZIP CODE

PHONE NO.

REFERRED BY

(802)595-9744

Beth M. Weatherbee R.N.

EMPLOYMENT DESIRED
POSITION

Licensed Nurse Assistant

ARE YOU
EMPLOYED?

YES

EVER APPLIED TO
THIS COMPANY BEFORE?

YES

SALARY DESIRED

May 31, 2017

negotiable

IF SO, MAY WE INQUIRE

WITH YOUR PRESENT EMPLOYER?

NO

DATE YOU CAN START

WHERE?

YES

NO

WHEN?

NO

EDUCATION HISTORY
NAME & LOCATION OF SCHOOL

GRAMMAR SCHOOL
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS OR
CORRESPONDANCE
SCHOOL

YEARS
ATTENDED

DID YOU
GRADUATE?

SUBJECTS STUDIED

Hardwick Elementary School

6 years

graduated

basic study

Hazen Union High School

3 years

still attending

basic study

Community College of Vermont

1 year

still attending

Medical Terminology
Human Biology

Green Mountain Technology and

Career Center, Hyde Park, VT

2 years

still attending

Allied Health

GENERAL INFORMATION
SUBJECTS OF SPECIAL STUDY/RESEARCH
WORK OR SPECIAL TRAINING/SKILLS CPR

for Healthcare Provider and First Aid through AHA, Licensed Nursing Assistant,
Personal Care Attendant, Emergency Medical Responder, Human Biology and Medical Terminology for college credit.

U.S. MILITARY OR
NAVAL SERVICE

Not at this time.

RANK

FORMER EMPLOYERS
DATE
MONTH AND YEAR

(LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)

NAME & ADDRESS OF EMPLOYER

SALARY

POSITIO
N

REASON FOR LEAVING

FROM September 2016

TO still attending

Hannafords, 80 Fairgrounds Plz,

Morrisville, VT 05661

$9.75/hr

Cashier

still working there

Laura Speare, 45 Granite Street

Greensboro, VT 05841

$10/hr

Child Care
Provider

school started. I work

summers with Laura.

FROM June 2016

TO August 2016

REFERENCES:

GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR
YEARS
NAME
ADDRESS
BUSINESS
KNOWN

Beth M. Weatherbee
Kyle Behrsing
Laura Speare

738 VT 15 West
Hyde Park, VT 05655
126 Hazen Union Dr
Hardwick, VT 05843
45 Granite Street
Greensboro, VT 05841

Allied Health Career

Instructor
High School English
Instructor
Employer

2
3
1

AUTHORIZATION
I certify that the facts contained in this application are true and complete to the best of my knowledge and
understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references and employers listed above to give
you any and all information concerning my previous employment and any pertinent information they may have,
personal or otherwise, and release the company from all liability for any damage that may result from utilization for
such information.
I also understand and agree that no representative of the company has any authority to enter into any agreement
for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in
writing and signed by an authorized company representative.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by
the Americans with Disabilities Act (ADA) and other relevant federal and state laws.
DATE

SIGNATURE

INTERVIEWED BY

DATE

REMARKS

NEATNESS

CHARACTER

PERSONALITY

ABILITY

HIRED

FOR
DEPT.

APPROVED: 1.

POSITION

WILL
REPORT

2.
EMPLOYMENT MANAGER

SALARY
WAGES

3.
DEPARTMENT HEAD

GENERAL MANAGER

This application for employment is sold only for general use throughout the United States. Adams assumes no responsibility and hereby disclaims any liability for the inclusion in this form of any questions
or requests for information upon which a violation of local, state and/or federal law may be based. It is the users responsibility to ensure that this forms use complies with applicable laws which change
from time to time.