Pre Employment Application Form – Fill Out and Use This PDF

POSITION DESIRED

❑ F/T

❑ P/T

PRE-EMPLOYMENT APPLICATION

SOURCE OF REFERRAL

Please Print in Black Ink or Type

LAST NAME

FIRST

MIDDLE INITIAL

SOCIAL SECURITY NO.

TELEPHONE NO.

ADDRESS

CITY OR BOROUGH

STATE

ZIP CODE

CITIZENSHIP

ARE YOU 18 YEARS OR OLDER

U.S. ARMED FORCES SERVICE – BRANCH OF SERVICE U.S.

❑ U.S. CITIZEN

❑ YES ❑ NO

❑ VETERAN

❑ DISABLED VETERAN

❑ RESIDENT ALIEN

DATE OF ENTRY

DATE OF DISCHARGE

❑ NON-RESIDENT ALIEN

IF NO, STATE AGE

ARMED FORCES OCCUPATION

PREVIOUS NEW YORK CITY EMPLOYMENT (AGENCY & DATES)

INDICATE ANY OTHER NAME USED ON EMPLOYMENT RECORDS

EDUCATION

ATTENDANCE

NAME AND ADDRESS OF SCHOOL

DIPLOMA &

EDUCATION

FROM

TO

INCLUDE FULL STREET ADDRESS,

MAJOR COURSE

DID YOU

DEGREE

CITY, STATE AND ZIP CODE

LEVEL

MO/YR

MO/YR

OF STUDY

GRADUATE

RECEIVED

NAME

❏ YES

HIGH SCHOOL

/

/

OR EQUIVALENT

ADDRESS

❏ NO

NAME

❏ YES

NURSING

/

/

❏ NO

ADDRESS

SCHOOL

NAME

❏ YES

COLLEGE OR

/

/

UNIVERSITY

ADDRESS

❏ NO

NAME

❏ YES

POST

/

/

GRADUATE

ADDRESS

❏ NO

PE 6 (REV. 8/04)

(Continue on reverse side)

EMPLOYMENT RECORD

LIST MOST RECENT EMPLOYMENT FIRST (IF MORE SPACE IS REQUIRED TO ACCOUNT FOR AT LEAST YOUR LAST 10 YEARS OF WORK EXPERIENCE, PLEASE

CONTINUE ON SEPARATE EMPLOYMENT RECORD SHEET AND ATTACH FIRMLY)

DATES EMPLOYED

NAME AND ADDRESS OF EMPLOYER

DESCRIPTION OF WORK (INCLUDE NUMBER AND KIND OF EMPLOYEES

MO. / YR.

SUPERVISED, IF ANY)

FROM

TO

PHONE NO. (

)

NATURE OF BUSINESS

SUPERVISOR'S NAME AND TITLE

EXACT TITLE OF YOUR POSITION

ANNUAL SALARY

REASON FOR LEAVING

DATES EMPLOYED

NAME AND ADDRESS OF EMPLOYER

DESCRIPTION OF WORK (INCLUDE NUMBER AND KIND OF EMPLOYEES

MO. / YR.

SUPERVISED, IF ANY)

FROM

TO

PHONE NO. (

)

NATURE OF BUSINESS

SUPERVISOR'S NAME AND TITLE

EXACT TITLE OF YOUR POSITION

ANNUAL SALARY

REASON FOR LEAVING

DATES EMPLOYED

NAME AND ADDRESS OF EMPLOYER

DESCRIPTION OF WORK (INCLUDE NUMBER AND KIND OF EMPLOYEES

MO. / YR.

SUPERVISED, IF ANY)

FROM

TO

PHONE NO. (

)

NATURE OF BUSINESS

SUPERVISOR'S NAME AND TITLE