Home                 Hillsborough County                                    Employment Application

                      329 Mast Road - Suite 112                                                       An Equal Opportunity Employer

                      Goffstown, NH  03045                

                                     

PLEASE PRINT CLEARLY                                                                                             Date: _______________________

 

Name ___________________________________________________ Social Security No. ______________________________

                       FIRST                                            LAST

 

Present Address ___________________________________________________________ Phone ________________________

                            NO. STREET

 

__________________________________________________________________ Second Phone ________________________

CITY                                                                                        STATE                             ZIP

 

Position(s) applied for _____________________________________________________________________________________                      

 

Seeking:                 ___ Full Time           ___ Part Time                ___ Per Diem          _____________Hours per Week

 

Available to Work:   ___ Days                 ___ Evenings                 ___ Nights         ___ Weekends              ___Holidays

 

Days and Times Available: ___________________________________________   Date Available to Start:  _______________

 

Foreign languages you speak fluently: ___________________  Read: ___________________  Write: ___________________

 

Are you at least 18 years old?  _____________  How did you hear about this position? _______________________________

 

Have you ever worked for Hillsborough County?   ___ Yes    ___ No    Where? _______________________   When? _______

 

Have you legal permission to work in the United States?   ___ Yes   ___ No

 

Have you ever been convicted of a felony?            ___ Yes    ___ No          If yes, please explain: ______________________

 

EMPLOYMENT HISTORY

LIST OF EMPLOYERS WITH MOST CURRENT LISTED FIRST

1. MO/DAY/YR STARTED

 

 

EMPLOYER’S NAME                                                                     TEL # w/ Area Code

SUPERVISOR’S NAME

   MO/DAY/YR ENDED

 

 

STREET                                                                            CITY/STATE

FINAL ANNUAL WAGE

$

DEPT/TITLE/DUTIES

 

AVG HRS WORKED/WEEK

REASON FOR LEAVING:

2. MO/DAY/YR STARTED

 

 

EMPLOYER’S NAME                                                                     TEL # w/ Area Code

SUPERVISOR’S NAME

   MO/DAY/YR ENDED

 

 

STREET                                                                            CITY/STATE

FINAL ANNUAL WAGE

$

DEPT/TITLE/DUTIES

AVG HRS WORKED/WEEK

REASON FOR LEAVING:

 

3. MO/DAY/YR STARTED

 

 

EMPLOYER’S NAME                                                                     TEL # w/ Area Code

SUPERVISOR’S NAME

   MO/DAY/YR ENDED

 

 

STREET                                                                            CITY/STATE

FINAL ANNUAL WAGE

$

DEPT/TITLE/DUTIES

 

AVG HRS WORKED/WEEK

REASON FOR LEAVING:

4. MO/DAY/YR STARTED

 

 

EMPLOYER’S NAME                                                                     TEL # w/ Area Code

SUPERVISOR’S NAME

   MO/DAY/YR ENDED

 

 

STREET                                                                            CITY/STATE

FINAL ANNUAL WAGE

$

DEPT/TITLE/DUTIES

 

AVG HRS WORKED/WEEK

REASON FOR LEAVING:

 

Under what other names have you been employed?  ___________________________________________________________________

Have you worked at any other jobs in the past 10 years?       ___ Yes                ___ No