SOCIAL SECURITY #: ______-________-_________

NAME: __________________________________________________________

ADDRESS_________________________________________________________

PHONE NUMBER_________________________ EMAIL______________________

CAN YOU PASS A PRE-EMPLOYMENT DRUG TEST? Yes No

ARE YOU LEGALLY AVAILABLE FOR EMPLOYMENT IN THE UNITED STATES? Yes No

ARE YOU AVAILABLE TO WORK JUNE THRU AUGUST? Yes No - IF NOT, WHEN?__________

REFERRED BY?______________________________________________

FIRST AID__________________________ CPR____________________________

EMERGENCY MEDICAL TECHNICIAN_________________

EMERGENCY TRAUMA TRAINING_________

COMMERCIAL DRIVERS LICENSE______________________________________

OTHER______________________________________________________________

NAME____________________________________________________________________

ADDRESS/PHONE__________________________________________________________

POSITION/RELATION_______________________________________________________

YEARS ACQUAINTED_______________________________________________________

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION.  I UNDERSTAND THAT  MISREPRESENTATION OF INFORMATION REQUESTED IS CAUSE FOR DISMISSAL. 

IN CASE OF EMERGENCY NOTIFY: _________________________________________

PHONE # : ______________________

ADDRESS: ______________________________________

SIGNATURE: ______________________________________ DATE:________________