Date:

Name (Last, First, Middle):

Address:

How long have you lived at this address?

Home phone number:

Cell phone number:

Business phone number:

May we call you at your business phone number?

• Yes

• No

Email address:

Are you 18 years of age or older?

• Yes

• No

Have you ever been employed by Second Presbyterian Church?

• Yes

• No

Are there any restrictions on days or hours you are available to work?

• Yes

• No

Are you seeking work:

• Full time

• Part time

What date can you start?

What position are you seeking?

What wage are you seeking?

Please list office machines you can operate:

List computer programs you are proficient in:

Have you ever been bonded?

• Yes

• No

Have you been convicted of any crimes in the past years, excluding misdemeanors and summary offenses, which have not been annulled, expunged or sealed by a court?

• Yes

• No

Do you have a valid driver's license?

• Yes

• No

What state issued your driver's license?

When does your driver's license expire?

Is a car available to you for daily use?

• Yes

• No

Have you received any driving citations in the last 24 months?

• Yes

• No

EDUCATION -- Education will be considered only to the extent relevant for the position for which you are applying.

Please tell us the name, address and telephone number of your grade school.

Select the number of years completed.

Choose... 1 2 3 4 5 6 7 8

Dates from:

Attended to:

Please tell us the name, address and telephone number of your high school

Select the number of years completed.

Choose... 1 2 3 4

Dates from:

Attended to:

Did you graduate?

• Yes

Please tell us the name, address and telephone number of the college you attended.

Select the number of years completed.

Choose... 1 2 3 4 5

Dates from:

Attended to:

What was your major?

Did you graduate?

• Yes

Please tell us the name, address and telephone number of any other educational institution you attended.

How many years did you complete?

Dates to

Attended to:

What was your major?

Did you graduate?

• Yes

EMPLOYMENT HISTORY

Company name:

Telephone number:

Address:

Position:

Date started:

Date you left:

Supervisor's name and title:

Reason for leaving:

Wage:

Company name:

Telephone number:

Address:

Position:

Date started:

Date you left:

Supervisor's name and title:

Reason for leaving:

Wage:

Company name:

Telephone number:

Address:

Position:

Date started:

Date you left:

Supervisor's name and title:

Reason for leaving:

Wage:

May we contact the employers llisted above?

• Yes

Tell us about your membership in professional and civic organizations, special accomplishments, awarrds, etc.

ADDITIONAL INFORMATION

Are you an U.S. citizen or an alien authorized to work in this country?

• Yes

• No

If you are offered employment with Second Presbyterian Church, you will be required, by federal law, to furnish documents showing you are either a U.S. citizen or an authorized alien within three days of hire. Individuals who do not furnish these documents cannot work for the company.

In case of emergency, please contact:

Telephone number:

Address:

Place of employment:

Relationship:

A consumer report (background screening report) and/or an investigative consumer report which may include information concerning your character, employment history, general reputation, personal characteristics, police record, education, qualifications, motor vehicle record, mode of living, and/or credit and indebtedness may be obtained in connection with your application for and/or continued employment with Second Presbyterian Church. A consumer report and/or an investigative consumer report may be obtained at any time during the application process or during your employment with the Second Presbyterian Church. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for emp0loyment is an investigation into your education and/or employment history conducted by Safe Hiring Solutions LLC, P.O. Box 295, Danville, IN 46122 888-215-8296.

I hereby authorize Second Presbyterian Church to obtain either a consumer or an investigative consumer report about me from a consumer reporting agency and to consider this information when making decisions regarding my employment and/or continued employment at Second Presbyterian Church. I understand that I have rights under the Fair Credit Reporting Act, including rights discussed above. This report may be delivered in either written or electronic form.

• Accept

• Decline

If any opening occurs and you are qualified, we will be in touch with you. We will be glad to give this record active consideration for a period of 30 days.