Online Application for Employment

We are an Equal Opportunity Employer.

Position applying for*
Location of Position*
Today's Date*
Date Format: MM slash DD slash YYYY
First Name*
Last Name*
Middle Initial
Social Security Number*
Email Address*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone Number*
Cell Phone Number
Employment Questionnaire
1. Are you a U.S. Citizen?*
- Yes
- No
2. If you are under age eighteen, do you have an employment certificate?
- Yes
- No
3. Are you prevented from lawfully becoming employed in the United States because of Visa or immigration status? Proof of citizenship or immigration status will be required upon employment?*
- Yes
- No
4. How did you learn about us? (Please check all that apply)
- Advertisement
- Friend
- Walk-in
- Employment Agency
- Relative
- Referred by Coalition Employee
Name of Employee
5. Are you currently employed?*
- Yes
- No
6. Have you completed an application with us before?*
- Yes
- No
If yes, please provide the date *
7. Have you ever been employed with us before?
- Yes
- No
8. Are you currently on lay-off status and subject to recall?*
- Yes
- No
9. If required, can you travel?*
- Yes
- No
10. Availability to Work*
- Full Time
- Part Time
- Shift Work
- Temporary
11. Do you have relatives who currently work for the Coalition for the Homeless?*
- Yes
- No
Name of Relative
Location of Employment
Education
Name & Address of High School
Years Completed
Did you graduate?
- Yes
- No
Did you receive diploma/degree?
- Yes
- No
Name & Address of College
Years Completed
Did you graduate?
- Yes
- No
Did you receive diploma/degree
- Yes
- No
Major/Subject of Study
Name & Address of Trade/Business School
Years Completed
Did you graduate?
- Yes
- No
Did you receive diploma/degree?
- Yes
- No
Major/Subject of study
Describe any honors you received or state any additional information you feel may be helpful.
Describe any specialized training, apprenticeship, skills and extra-curricular activities.
Work History

Please list your work experience for the last 4 years beginning with the most recent job held. Include any job-related military service assignments.

Employer 1
Employer Name
Job Title
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone
Start Salary
End Salary
Name of Last Supervisor
Employed from date
Date Format: MM slash DD slash YYYY
Employed to date
Date Format: MM slash DD slash YYYY
May we contact your supervisor?
- Yes
- No
Reason for Leaving (be specific)
Duties Performed
Employer 2
Employer Name
Job Title
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone
Start Salary
End Salary
Name of Last Supervisor
Employed from date
Date Format: MM slash DD slash YYYY
Employed to date
Date Format: MM slash DD slash YYYY
May we contact your supervisor?
- Yes
- No
Reason for Leaving (be specific)
Duties Performed
Employer 3
Employer Name
Job Title
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone
Start Salary
End Salary
Name of Last Supervisor
Employed from date
Date Format: MM slash DD slash YYYY
Employed to date
Date Format: MM slash DD slash YYYY
May we contact your supervisor?
- Yes
- No
Reason for Leaving (be specific)
Duties Performed
License/Registry Information
Please complete if a license is required for the position you are applying for.
License 1
Type of License/Registry
State
License Number
Original License Date
Date Format: MM slash DD slash YYYY
Most Recent Renewal Date
Date Format: MM slash DD slash YYYY
License Expiration Date
Date Format: MM slash DD slash YYYY
License 2
Type of License/Registry
State
License Number
Original License Date
Date Format: MM slash DD slash YYYY
Most Recent Renewal Date
Date Format: MM slash DD slash YYYY
License Expiration Date
Date Format: MM slash DD slash YYYY
Have you applied for reciprocity in D.C.?
- Yes
- No
- Not Required
Has your license ever been suspended or revoked?
- Yes
- No
If your license HAS ever been suspended or revoked, please explain
Foreign Languages
Please indicate any foreign languages you speak, read, or write and your level of proficiency
I SPEAK
I speak the indicated foreign language(s)
I READ
I read the indicated foreign language(s)
I WRITE
I write in the indicated foreign language(s)
Professional Activities
List professional, trade, business or civic activities and offices held. You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or handicap or other protected status:
References

Give name, address and telephone number of three previous supervisors and three professional references.
Previous Supervisors
Name of Previous Supervisor
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Name of Previous Supervisor
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Name of Previous Supervisor
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Professional References
Name of Professional Reference
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Name of Professional Reference
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Name of Professional Reference
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. The applicant understands that neither this document nor any offers of employment from the employer constitute an employment contract unless a specific document to that effect is executed by the employer and employee in writing.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

All information provided by the applicant on this form is subject to verification. Inability on our part to confirm statements made by you may prevent consideration for employment.

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.The Coalition is a drug free work environment and background checks will be required if there is a written offer of employment.

By typing my name, I hereby certify I have read, understand, and agree to the above applicant's statement.
Name of Personal Reference
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Personal Reference
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Personal Reference
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type your full name
Date

Contact

1234 Massachusetts Ave, NW, Suite C-1015
DC, Washington 20005
(202) 347-8870

Online Application for Employment

Employment Questionnaire

Education

Work History

Employer 1

Employer 2

Employer 3

License/Registry Information

License 1

License 2

Foreign Languages

Professional Activities

References

Previous Supervisors

Professional References

Applicant's Statement

Contact