ICAN Employment Application

First Name

Last Name

Address Line 1

City

State

Postal Code

Phone:

Salary Desired:

How Many Hours Can You Work Weekly?

Please note: this is a part time position only

When Are You Available To Start?

	Name of School	Location	Number of Years Completed	Major & Degree
High School
College
Other
Other
Other

Have You Ever Been Convicted of a Crime?

YesNo

If Yes, Please Explain:

Please List Two References From Previous Employers:

	Reference 1	Reference 2
Name:
Position:
Company:
Phone:
Email:

Please List Your Work Experiences From the Past 5 Years Beginning With Your Most Recent Job Held.

Work History 1

Name of Employer:

Name Of Supervisor:

Title:

Address:

Phone:

Pay or Salary:

Employment Dates:

Reason for Leaving:

List the Jobs you Held, Duties Performed, Skills Used or Learned, Advancements or Promotions While You Worked at This Company.

Work History 2

Name of Employer:

Name of Supervisor:

Title:

Address:

Phone:

Pay or Salary:

Employment Dates:

Reason for Leaving:

List the Jobs you Held, Duties Performed, Skills Used or Learned, Advancements or Promotions While You Worked at This Company.

Work History 3

Name Of Employer:

Name of Supervisor:

Title:

Employment Dates:

Address:

Phone:

Pay or Salary:

Reason for Leaving:

List the Jobs you Held, Duties Performed, Skills Used or Learned, Advancements or Promotions While You Worked at This Company.

May We Contact Your Present Employer?

YesNo

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

Please Upload Your Resume:

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