COBYS Employment Application

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis, including race, color, age, sex, religion, or national origin.

Personal Information

Date

Name

First Middle Last

Present Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Permanent address (If different than present address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary phone number

Secondary phone number

Are you at least 21 years old?

Yes

How did you hear about the position?

Name of school

Referred by

Other

Hidden

Referred by or heard about through

Employment Desired

Position

Start Date

Salary desired

Have you ever applied to COBYS before?

Yes

What position?

When

Education

High School

Name and location of school

Number of years completed

Did you graduate?

Yes

College or University

Name and location of school

Number of years completed

Did you graduate?

Yes

Subjects studied and degree(s) received

Other formal education

Name and location of school

Number of years completed

Did you graduate?

Yes

Subjects studied and degree(s) received

Former Employment

List below your last four employers, beginning with the most recent.

Employer

Name, Address and Phone Number

Date (From)

Date (To)

Position

Reason for leaving

Employer

Name, Address and Phone Number

Date (From)

Date (To)

Position

Reason for leaving

Employer

Name, Address and Phone Number

Date (From)

Date (To)

Position

Reason for leaving

Employer

Name, Address and Phone Number

Date (From)

Date (To)

Position

Reason for leaving

References

Please provide two professional references and one personal reference. References shall be from people who have known you for at least one year. No relatives, please.

Name - Professional reference-1

First Last

Home Phone

Work Phone

Relationship

Years acquainted

Name - Professional reference-2

First Last

Home Phone

Work Phone

Relationship

Years acquainted

Name - Personal reference

First Last

Home Phone

Work Phone

Relationship

Years acquainted

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period of time and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice. I hereby authorize the release to COBYS Family Services of any and all information relative to my employment, including but not limited to dates of employment, attendance records, performance ratings, rates of pay and eligibility for re- employment. I authorize its release without penalty or liability. A photocopy of this authorization shall be considered as valid as the original.

Signature

Date