Apply – Eastern Nebraska Human Services Agency Human Resources

Name*

First Middle Last

Last 4 Digits of Social Security Number*

Address*

Street Address City State ZIP Code

Phone Number*

E-mail Address*

Position*

Education Level*

Degree/Area of Study*

Other*

Please elaborate

General Information

Can you provide documents to prove your citizenship and age?*

Yes
No

If not a U.S. citizen do you legally have the right to remain and work in the U.S.?*

Yes
No

Have you ever worked for this agency?*

Yes
No

Under what name?*

Are any of your relatives employed by this agency?*

Yes
No

Please give names.*

How did you learn about this agency?*

Were you referred by an Agency employee?*

Yes
No

By whom?

Qualifications, Skills and Unpaid Experience

List Qualifications and skills related to the position desired, such as professional or technical licenses, special training, computer skills, etc.*

List any non-paid or volunteer experiences that are relevant to the position applied for.

List any gaps in employment history including an explanation.

Most Recent Employer

Name of Most Recent Employer*

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Job Title*

Duties Performed*

Start Date*

End Date*

Wage with most recent employer*

Reason for leaving*

May we contact current employer?

Yes
No

Second Most Recent Employer

Name of 2nd most recent employer

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Job Title

Duties Performed

Start Date

End Date

Ending Wage

Reason for leaving 2nd most recent employer

Third Most Recent Employer

Name of 3rd Most Recent Employer

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Job Title

Duties Performed

Start Date

End Date

Ending Wage

Reason for leaving 3rd most recent employer

Do you have a valid driver's license?*

Answering "no" will not necessarily exclude you from employment.

Yes
No

Available for:

Regular Full-time
Regular Part-time
Substitute

Hours you are available to work:*

Select all that apply

Select All
Mornings 6 AM - 8 AM
Days 7 AM - 5 PM
Evenings 2 PM - 10 PM
Overnights 10 PM - 10 AM
Saturdays ALL DAY
Sunday ALL DAY

Brief Comments

Authorization

I authorize the investigation of all statements contained on this form. The organization or person names as a reference is authorized to give the information requested regarding me and they are hereby released from all liability for issuing such information.

Name

Today's Date*

Phone

This field is for validation purposes and should be left unchanged.