COMPANY OR EMPLOYER NAME:
POSITION APPLIED FOR: 
APPLICANT TELEPHONE: 
Employment 
Application sociais 
SOCIAL SECURITY NUMBER: 
YOUR NAME: 
Last 
ADDRESS: 
Dres 
No 
First 
Middle ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE U.S.A.? Yes No (If yes, verification will be required.) I AM SEEKING A PERMANENT POSITION: IF NECESSARY FOR THE JOB I AM ABLE TO: 
Work (which shifts)? Select: Work overtime? Select: Provide a valid Alaska Drivers License ? Select: 
Are you able to perform the essential functions of the position with or without accommodations? 
Yes No 
19_ 
21_ 
IF NECESSARY FOR THE JOB, ARE YOU OVER (Please mark one) 14_ 15_ 16_ 18_ I WILL BE ABLE TO REPORT TO WORK DAYS AFTER BEING NOTIFIED THAT I AM HIRED.
EDUCATION: 
Yrs. Completed 
Field of Study 
Graduate or Degree 
High School College/University Business/Technical 
Other (May include grammar school) 
MILITARY SERVICE: 
MILITARY SERVICE: 
Yes 
Yes 
No 
Duty/Specialized Training: 
REFERENCES: List two personal references who are not relatives or former supervisors. 
Name 
Address 
Telephone 
Occupation 
Years known 
Name 
Address 
Telephone 
Occupation 
Years known 
EMPLOYMENT: 
List last employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here, in the summary (following this section), or use an extra sheet of paper if necessary. 
Employer Name and Address 
Position Title/Duties Skills 
Dates Employed from
to 
Reason for leaving 
Supervisor's Name: 
Telephone: 
Employer Name and Address 
Position Title/Duties Skills 
Dates Employed from 
to 
Reason for leaving 
Supervisor's Name: 
Telephone: 
Developed at employer request by the Alaska Department of Labor and Workforce Development, Employment Security Division 
genapp (r03/00)