45

EMPLOYMENT APPLICATION
1911 Superior Street, Sandusky, Ohio 44870
(419) 626-6220 Fax (419) 626-2061

www.humanesocietyoferiecounty.org AnimalsRUS5@aol.com
The Humane Society of Erie County is an Equal Opportunity Employer. The Humane Society does not unlawfully discriminate on the basis of race, color, sex, marital status, age, creed, religion, national origin, disability, sexual orientation, veteran status or any other classification protected by applicable law.

(PLEASE PRINT)

Name:_______________________________________________________________
Last First Middle Initial

Position Applying for:___________________________________________________

PLEASE read all instructions carefully and complete all sections of the application completely and accurately. Your application may be ineligible for review if information is omitted or inaccurate. ATTENTION APPLICANT: It is your responsibility to provide sufficient information on this application to indicate that you meet the minimum qualifications for the job for which you wish to be considered. If requested in advance and in compliance with the Americans with Disability Act (ADA), The Humane Society will provide reasonable accommodation to applicants in need of accommodation so as to permit access to the application, interviewing and selection process.
Resume submitted? Yes No Social Security #:_____________________________ No

Have you been employed under another name? Yes

If yes, what name?_______________________________________________________ Current Address:_________________________________________________________ Phone: (home)___________________________ (cell)___________________________ (e-mail)_____________________________________________ Are you 18 years of age or older? Yes No No

Have you ever been employed by The Humane Society of Erie county? Yes

If yes, dates employed______________________________________________________ Do you have a relationship with a current employee or a Board Member of The Humane Society of Erie County? Yes No If yes, please explain:_________________________________________________________________ Are you legally eligible for employment in the United States? Yes
Proof of citizenship or immigration status will be required upon employment

No

Are you interested in: [Check all that are applicable]

Full Time

Part Time

Seasonal

Days/hours available to work? (Shifts vary from 8:00 a.m. - 8:30 p.m. Sunday Saturday)_______________ Will you work overtime? Yes No No Years Completed Diploma/ Degree

Are you currently enrolled in or do you plan to return to school? Yes Name/Location of School

EDUCATION
High School/GED

Major

Business/Technical

College/University

Other job related training Licenses: List all relevant certificates or licenses (including valid drivers license) Granted by (License Board) Type of License License Number State & Expiration Date

12345678901234567890123456789012123456

Have you ever been convicted of a felony within the last seven (7) years or a misdemeanor of animal abuse within the past seven (7) years? Yes / No A conviction record will not necessarily disqualify you for employment considerations. Are you or have you ever been a sex offender registered with any Federal, State or Local Government Agency, including any listed on a pubic website? Yes No

EMPLOYMENT (Including Military Service)

Begin with your present or most recent employment. Account for all periods of time and any period of unemployment. Be sure to include any volunteer experience which is related to the job for which you are applying. Employer
Address City State Zip Phone

Dates Employed From - To

Work Performed

Hourly Rate/Salary Start - Final

Position Reason for leaving:

Supervisor

May we contact the employer? Yes Ref check done by: Date

No

Employer
Address City State Zip Phone Position Reason for leaving: Supervisor

Dates Employed From - To

Work Performed

Hourly Rate/Salary Start - Final May we contact the employer? Yes Ref check done by: Date

No

Employer
Address City State Zip Phone Position Reason for leaving: Supervisor

Dates Employed From - To

Work Performed

Hourly Rate/Salary Start - Final May we contact the employer? Yes Ref check done by: Date

No

SPECIAL SKILLS [Check all that apply]

Customer Service Graphic Arts Banking/Accounting Veterinary/Medical Teacher/Trainer Computer Skills

Other ______________________________________________________________________ Any training or experience related to the care of animals? Personal characteristics which would qualify you for employment at The Humane Society:

PROFESSIONAL REFERENCES (NO RELATIVES, PLEASE)

Name________________________________________________Occupation______________________ Addess______________________________________________________________________________ Phone______________________ Capacity Known______________________________________________________________________

Reference Check done by: Date:

Number of years__________________

Name________________________________________________Occupation______________________ Addess______________________________________________________________________________ Phone______________________ Capacity Known______________________________________________________________________

Reference Check done by: Date:

Number of years__________________

Name________________________________________________Occupation______________________ Addess______________________________________________________________________________ Phone______________________ Capacity Known______________________________________________________________________

Reference Check done by: Date:

Number of years__________________

Applicants Authorization This application is invalid without the signature of the applicant.
I authorize the references listed above to give you any and all information concerning my previous employment and any other pertinent information and release all parties from all liability for any damage that may result from furnishing same to you. I certify, under penalty of perjury, that the facts contained in this application are true and complete and contain no misrepresentation and is presented 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 of such information.

Signature_____________________________________________ FOR OFFICE USE ONLY ___________ Date:________ Comments:

Date____/_____/____

Interviewers Name:____________________________ Title