HSNMB - Employment Application

Last Name*

First Name*

Middle Name

Street Address*

City*

State*

ZIP*

Phone*

Email*

Do you have a current Driver’s License and are you able to transport animals in your vehicle?*

Yes
No

Have you ever been convicted of a crime (excluding minor traffic violations)? Conviction of a crime will not necessarily bar employment.*

Yes
No

Do not report any conviction for which the records have been officially expunged.

Date of conviction?*

Please label the year only

If yes, please explain*

How soon can you report to work?*

Do you have animal related employment experience?*

Yes
No

If yes, please describe:*

Educational Data

Did you successfully complete elementary school?*

Yes
No

Did you successfully complete junior high school?*

Yes
No

Did you successfully complete senior high school?*

Yes
No

If you did not graduate from high school, have you received a GED?*

Yes
No

School's attended

Name of last school attended

Location of last school attended

List major courses taken

College, University, or other training

Name of College, University, or other training

Location of College, University, or other training

Major or Specialty

Degree or Certificate received?

If yes, give title. If No, number semester hours or credits completed.

Employment History

Give employment record as completely as possible starting with your present or last position not to exceed past 15 years. Attach additional sheets if necessary. Note: This application must be fully completed whether or not a resume is submitted.

How many previous jobs have you had in the past 15 years?*

Employer / Firm #1

Employer / Firm #1*

Address #1*

Date started #1*

Date finished #1*

Phone #1*

Starting Salary #1*

Ending Salary #1*

Type of business? #1*

Reason for leaving? #1*

Were you full-time or part-time? #1*

Full-time
Part-time

Title of position and duties #1*

Who was your immediate supervisor? #1*

Their title? #1*

Employer / Firm #2

Employer / Firm #2*

Address #2*

Date started #2*

Date finished #2*

Phone #2*

Starting Salary #2*

Ending Salary #2*

Type of business? #2*

Reason for leaving? #2*

Were you full-time or part-time? #2*

Full-time
Part-time

Title of position and duties #2*

Who was your immediate supervisor? #2*

Their title? #2*

Employer / Firm #3

Employer / Firm #3*

Address #3*

Date started #3*

Date finished #3*

Phone #3*

Starting Salary #3*

Ending Salary #3*

Type of business? #3*

Reason for leaving? #3*

Were you full-time or part-time? #3*

Full-time
Part-time

Title of position and duties #3*

Who was your immediate supervisor? #3*

Their title? #3*

References

Business or Professional References Only – (Please do not list relatives) Make sure you answer all the questions on this form. If you do not fill it out completely, it may result in the rejection of this application.

Reference #1

Name #1*

Address #1*

Phone #1*

Occupation #1*

Years known #1*

Reference #2

Name #2*

Address #2*

Phone #2*

Occupation #2*

Years known #2*

Reference #3

Name #3*

Address #3*

Phone #3*

Occupation #3*

Years known #3*

Please check if you agree to the following

I have the ability to stand for extended periods of time and am able to bend and reach to perform work duties.
I have the ability to lift and carry 50lbs without assistance.
I have the ability to interact with dogs and cats including aggressive, stray, sick or injured animals.
I am able to handle seeing and dealing with animals that have been abused, neglected or treated cruelly.
I have the ability to learn to/perform examining, vaccinating, medicating and venipuncture on animals.
I have open availability and can work weekends and holidays.
I have excellent customer service skills and am comfortable working with the public.

If you do not have open availability and can not work weekends and holidays, please explain why*

Signature*

May we contact your present employer?*