THE IRIS NETWORK
189 Park Avenue
Portland, ME 04102
(207) 774-6273
EMPLOYMENT APPLICATION
Date:
NAME:____________________________________ SSN:
ADDRESS: __________________________________________________________
HOME PHONE: (_____)___________ BUSINESS PHONE: (____)_____________
POSITION APPLYING FOR: ___________________________________________
How did you learn of the position vacancy for which you are applying?
EMPLOYMENT HISTORY: Beginning with your most recent job, list your complete employment record, including military service, in chronological order. May we contact your current place of employment? _____ Yes _____ No
May we contact your present supervisor? _____ Yes _____ No
Dates: From _____________ To ______________ Salary:______________
Job Title: ______________________ Supervisor: _____________________
Employer: ________________________ Phone: (_____)_______________
Address of employer: ____________________________________________
Reason for leaving:
Dates: From _____________ To ______________ Salary:______________
Job Title: ______________________ Supervisor: _____________________
Employer: ________________________ Phone: (_____)_______________
Address of employer: ____________________________________________
Reason for leaving:
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Dates: From _____________ To ______________ Salary:______________
Job Title: ______________________ Supervisor: _____________________
Employer: ________________________ Phone: (_____)_______________
Address of employer: ____________________________________________
Reason for leaving:
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Dates: From _____________ To ______________ Salary:______________
Job Title: ______________________ Supervisor: _____________________
Employer: ________________________ Phone: (_____)_______________
Address of employer: ____________________________________________
Reason for leaving:
EDUCATION: List in order High School, College, Vocational, etc.
School Location Attendance Graduated
From – To Yes –No
ADDITIONAL INFORMATION: Please tell us of any special skills, publications, awards, volunteer experience, etc., which you feel should be considered in evaluating your application.
REFERENCES: List the names and addresses of three people who are qualified to assess your training and experience.
Name: ________________________________ Home Phone: (_____)_____________
Address: ______________________________________________________________
Business or Profession: __________________________________________________
Years known: _____ Business Phone: (_____)_____________
Business Address:_______________________________________________________
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Name: ________________________________ Home Phone: (_____)_____________
Address: ______________________________________________________________
Business or Profession: __________________________________________________
Years known: _____ Business Phone: (_____)_____________
Business Address:_______________________________________________________
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Name: ________________________________ Home Phone: (_____)_____________
Address: ______________________________________________________________
Business or Profession: __________________________________________________
Years known: _____ Business Phone: (_____)_____________
Business Address:_______________________________________________________
Have you ever been convicted of a felony or first-degree misdemeanor?
____ Yes ____ No
If yes, please indicate the date, nature of the offense, sentence, and any additional information that you feel should be considered. A conviction record will not necessarily be a bar to employment. Factors such as age and time of the offense, seriousness and nature of the violation and rehabilitation will be taken into account.
Veteran Status: Please check if any of the following are applicable. See the following page for definitions.
______ Vietnam Era Veteran ______Disabled Veteran ______Veteran
Are you a citizen of the U.S.? ______ Yes ______ No
Driver’s License # ______________________________ State Issued: _____________
I hereby certify that all statements made in this application are true, and I agree and understand that any misstatements of material facts may cause forfeiture on my part of all rights to employment with The Iris Network. The Iris Network is authorized to conduct a background investigation to verify my qualifications and experience.
Signed:___________________________________________ Date: ______________
Definition of Veteran Status
Vietnam Era Veteran: Veteran of the Vietnam era means a person who served on active duty for more than 180 days, any part of which occurred between August, 1964 and May 7, 1975 and was discharged or released therefrom with other than a dishonorable discharge or was discharged or released from active duty for a service-connected disability if any part of such active duty was performed between August 5, 1964 and May 7, 1975.
Disabled Veteran: A person (1) entitled to disability compensation from the Veteran’s Administration for a disability rating 30% or more, or (2) whose release from active duty was for a disability incurred or aggravated in the line of duty.
July 2002