APPLICATION FOR EMPLOYMENT
Please provide all information requested.

 
Last Name:
First Name:
Middle:
Street address:
City:
State:
Zip:
Home phone:
Message number:
Email:

POSITION DESIRED

Position Applied for: 

Desired salary: Date Available:
    Type of work:  Full Time:    Part time: Either

PERSONAL INFORMATION
If hired, can you present evidence of your U.S. Citizenship or proof of your legal right to live and work in the United States?
Yes
 No
Are you at least 18 years of age or older? If “no,” a work permit may be required.
Yes
 No
For reference purposes, have you worked or attended school under a former name?
If yes, please list former name(s):
Yes
 No
Have you ever worked for House Ear Institute?
Yes
 No
Are any relatives or members of your household currently employed by House Ear Institute?
Yes
 No
Are you able to perform the essential functions of the position applied for, either with or without reasonable accommodation?
Yes
 No
Have you ever been convicted of a criminal offense (other than convictions relating to marijuana that are more than two years old and/or convictions that have been sealed, expunged or eradicated), and/or arrested for a crime for which trial is now pending?
Yes
 No
If yes, please explain:
(Note: A conviction is not an automatic bar to employment. The nature of the offense, date of offense, the surrounding circumstances and relevance of the offense to the position applied for will be considered.)
Have you ever been discharged from any employment, asked to resign or advised that if you did not resign, your employment would be terminated?
Yes
 No
If yes, please explain:
The House Ear Institute is an Equal Opportunity Employer and does not unlawfully discriminate in employment. No questions on this application are used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify the Director of Human Resources.
EDUCATION AND TRAINING
Type of school
Name and Location
Years completed
Major & Degree
Did you Graduate?
High School /GED
Yes
 No
Trade / Technical School
Yes
 No
College or University
Yes
 No
Other
Yes
 No

SPECIAL SKILLS
Licenses/Certificates:
 Answer only if position applied for requires driver's license.  Do you have a valid California driver's license? Yes
 No
Keyboarding WPM:  Computer programs:
Office equipment:
Foreign Language Skills (optional):

Speak Read Write Interpret and or translate
Foreign Language Skills (optional):

Speak Read Write Interpret and or translate
Do you have any other experience, training, qualifications or skills which you feel makes you especially suited for the position applied for? Yes
 No
   
If yes please explain:
EMPLOYMENT HISTORY
For the last 10 years, starting with most recent, list each job held and account for all periods between jobs.
Provide additional sheets if necessary.
Current or most recent Employer: May we contact this employer? Yes
 No
Address:  Phone: Supervisor's Name: 
Date started: Date left:
Starting Salary: End Salary:
Title or Position: 
Duties and Responsibilities:
 Reason for leaving:
Account for periods of unemployment between jobs:
Previous Employer 2: May we contact this employer? Yes
 No
Address 

Phone  

Supervisor's Name: 
Date started: Date left:
Starting Salary: End Salary:
Title or Position: 
Duties and Responsibilities:
 Reason for leaving
Account for periods of unemployment between jobs:
Previous Employer 3: May we contact this employer?  Yes
 No
Address 

Phone  

Supervisor's Name: 
Date started: Date left:
Starting Salary: End Salary:

Title or Position: 

Duties and Responsibilities:
 Reason for leaving

Account for periods of unemployment between jobs:
Previous Employer 4: May we contact this employer? Yes
 		 No

Address: 

Phone  

Supervisor's Name: 
Date started: Date left:
Starting Salary: End Salary:
 Title or Position: 
Duties and Responsibilities:
 		 Reason for leaving
Account for periods of unemployment between jobs:
CERTIFICATION
Important, please read carefully. 
(To be signed and dated in person, at time of interview.)
I hereby certify that the information on this application and all other information otherwise provided is true and correct. I understand that any misrepresentations or omissions will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the House Ear Institute can terminate the relationship at will, with or without cause, at any time with or without prior notice. I further acknowledge that the only manner in which the “at will” nature of the employment relationship can be altered is by means of a specific written agreement signed by me and the House Ear Institute’s Chief Executive Officer.

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.  Please submit completed form. Signature below to be provided at time of interview.
Applicant's Signature:________________________
Date:________________
     (To be signed and dated in person, at time of interview.)