Employment Form

	1301 S. 11th St. Belleville, IL. 62223 618-235-3712	Belleville Area Humane Society Application for Employment
Personal Information
Name		SSN
Street Address		City, State, Zip
Phone		Refered by:
Employment Desired
Position Desired:		Start date:
		Salary Desired:
Are you currently employeed?	Yes No	May we contact your present employer?	Yes No
Are you at least 18 years old?	Yes No
Do you have any physical limitations?
Education History
School Name
School Address
School Level		Years Attended	to
Did you graduate?	Yes No	Which Degree(s)?

School Name
School Address
School Level		Years Attended	to
Did you graduate?	Yes No	Which Degree(s)?
Work History
Employer
Position
Phone Number		From/To	to
Salary		Reason you left

Employer
Position
Phone Number		From/To	to
Salary		Reason you left

Employer
Position
Phone Number		From/To	to
Salary		Reason you left
References
Name		Phone #
Business		Notes

Name		Phone #
Business		Notes

Name		Phone #
Business		Notes
Authorization
"I certify that the facts contained in this application are true and complete 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 its utilization."
Signature		Date
Please print this page and then sign and date. Official acceptance of this application can only be done in person at the shelter by a shelter manager at this time.
	Click here to clear all fields above and start over.		To submit this via email for unofficial review, click here.
Please note that the inclusion of your Social Security Number and other personal information via email submission is your responsibility. Email is NOT considered secure for transmission of this type of information. Submission is available only for those that have no wish to hide or protect their personal information. PLEASE DO NOT SEND VIA EMAIL IF YOU DO NOT WISH TO BROADCAST YOUR PERSONAL INFORMATION ACROSS THE INTERNET.