| How did you hear about Cincinnati State * |
| First Name * |
| Middle Name |
| Last Name * |
| Street Address * |
| City * |
| State * |
| Zip * |
| Telephone * |
| E-mail Address |
| Position(s) applied for * |
| If employed and under 18, can you furnish a work permit? (Yes/No) * |
| Have you previously applied for employment with Cincinnati State? (Yes/No) * |
| Referred by a Cincinnati State employee? * (Yes/No; if Yes, who?) |
| Are you related to any Cincinnati State employee? (Yes/No; if Yes, what is their relationship to you?) * |
| Are you employed now? (Yes/No) * |
| Are you legally eligible for employment in the United States? (Yes/No) * |
| When would you be available for work? * |
| At what times are you available to work? (Full-time, Part-time, Shift work, Temporary, Day, Evening) * |
| Can you travel if the job requires it? (Yes/No) * |
| Have you ever been convicted of a felony? (Yes/No; if yes, why?) * |
| School Name |
| Years Completed |
| Diploma/Degree |
| Describe Course of Study |
| Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities |
| School Name |
| Years Completed |
| Diploma/Degree |
| Year received (mm/yy) |
| Describe Course of Study |
| Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities |
| School Name |
| Years Completed |
| Diploma/Degree |
| Year received (mm/yy) |
| Describe Course of Study |
| Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities |
| School Name |
| Years Completed |
| Diploma/Degree |
| Year received (mm/yy) |
| Describe Course of Study |
| Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities |
| Certifications |
| Special Skills Summary |
| Employer Name |
| Date Employed From (mm/yy) |
| Date Employed To (mm/yy) |
| Starting Hourly Rate/Salary * required if Employee Name 1 is entered |
| Ending Hourly Rate/Salary * required if Employee Name 1 is entered |
| Address and Phone Number |
| Job Title |
| Supervisor |
| Reason for leaving |
| Work Performed |
| Employer Name |
| Date Employed From (mm/yy) |
| Date Employed To (mm/yy) |
| Starting Hourly Rate/Salary * required if Employee Name 2 is entered |
| Ending Hourly Rate/Salary * required if Employee Name 2 is entered |
| Address and Phone Number |
| Job Title |
| Supervisor |
| Reason for leaving |
| Work Performed |
| Employer Name |
| Date Employed From (mm/yy) |
| Date Employed To (mm/yy) |
| Starting Hourly Rate/Salary * required if Employee Name 3 is entered |
| Ending Hourly Rate/Salary * required if Employee Name 3 is entered |
| Address and Phone Number |
| Job Title |
| Supervisor |
| Reason for leaving |
| Work Performed |
| Additional Employment Information |
| May we contact your previous employers listed above? |
| May we contact your current employer? (Yes/No; if No, why?) |
| List professional, trade, business, or civic activities and offices held. (You may exclude those which indicate race, color, religion, sex or national origin) |