APPLICATION FOR EMPLOYMENT

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1 APPLICATION FOR EMPLOYMENT An Equal Opportunity Employer All applicants are considered without regard to race, color, gender, religion, national origin, age, marital or veteran status, mental or physical disability unrelated to job performance or any other legally protected status. POSITION APPLYING FOR: DATE: PERSONAL INFORMATION Legal name: First Last Middle Initial Address: Street City State Zip code Home Telephone: Other Telephone: Social Security #: Driver s License #: State: (if position requires operation of a company vehicle) Are you legally eligible for employment in the United States? Yes No United States Visa status, if applicable: Have you been convicted of a felony? Yes No If yes, please explain circumstances: Are you at least 18 years old? Yes No POSITION INFORMATION Position(s) applying for: Salary desired: $ Employment status desired: Full Time Part Time Temporary What hours are you available to work? If hired, when could you start? How did you hear about this job?

2 EMPLOYMENT HISTORY (Most recent first) 1. Job Title: Duties: 2. Job Title: Duties: 3. Job Title: Duties: 4. Job Title: Duties:

3 EDUCATION Type of school Name and Location Dates Attended Degree Received Subjects Studied Did you graduate? High School College / University Graduate School Tech School Other Special courses, training or experience acquired, including military experience: SKILLS Clerical / Office skills Computer skills Languages Other special knowledge or skills Name of software: PC Mac WPM Please describe any other experience, abilities or skills that might be helpful in considering your application: CERTIFICATION & AUTHORIZATION I hereby certify that all statements made in this application are true and correct to the best of my knowledge and belief. I understand that any misrepresentations or omissions of facts in this application are grounds for disqualification from further consideration or for dismissal from employment. I authorize the company to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. If employed, I agree to conform to the rules, regulations and policies of the company. I understand that I will be an employee at will and either the company or I may terminate my employment relationship at any time for any reason not in violation of law. I hereby acknowledge that I have read and fully understand the forgoing and seek employment under these conditions. Signature of Applicant Date

4 Questionnaire: 1. What do you believe the purpose of a Humane Society is? 2. Why do you wish to work at an animal shelter? 3. Do you have animal care experience? 4. Please define Euthanasia: 5. Explain your thoughts on euthanasia: 6. Do you have commitments that would prevent altering your schedule? If yes, explain: 7. Do you have allergies or health restrictions of any sort that would prevent bending, lifting up to 50 lbs, or hinder your cleaning ability? If yes, explain:

5 8. Do you have a current valid driver s license? Are you restricted in any way? Have you had any traffic violation convictions? If yes, explain: 9. Do you enjoy working with the public? 10. Are you available to work weekends? 11. Are you available to work holidays? Release of Information I do here by give my permission to the Vanderburgh Humane Society to contact any of the persons for whom I have been employed. Signature Date

6 (Please Read Carefully) Applicant s Certification and Agreement I understand that: 1. If I misrepresent or deliberately leave out a fact in my application, I may be refused employment or, if employed, I may be terminated. 2. The employer has my authority to thoroughly investigate my work, medical and personal history that is job related, and I herby consent to take any test whenever the employer deems it necessary in any employer investigation. I will hold no person, corporation or organization liable for my giving or its receiving information in such investigation. 3. If employed, I may terminate my employment at any time without notice or cause, and the employer may terminate or modify the employment relationship at any time without prior notice or cause. In consideration of my employment, I agree to conform to the rules and regulations of the employer. 4. Any doctor, hospital or testing laboratory may conduct medical tests, and I hereby give my consent to having all information released necessary for the employer to determine my abilities to perform job duties now or in the future. 5. The needs of the employer may make the following conditions mandatory: overtime, shift work, rotating work schedule, or a work schedule other than Monday through Friday. I accept these conditions of employment. 6. The employer is an equal opportunity employer. The employer does not discriminate in employment, and no question on this application is used for the purpose of limiting or excluding any applicant s consideration for employment on a basis prohibited by local, state or federal law. 7. If employed, I understand that my employment is for no definite period of time, and if terminated, the employer is liable only for wages or salary earned as of the date of termination. 8. I have read and agree to the above and hereby certify that the facts I have provided in my employment application are true and complete. 9. This application is current and active for only six months (180 days). At the conclusion of this time, if I have not had any contact from the employer and still wish to be considered for employment, it will be necessary for me to fill out a new application. Date Signature of applicant

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