Job Intake Form — The PLACE

Applicant Information

Full legal name

Preferred name (if different)

Date of birth

Social Security Number

Contact Information

Street address

City

State

ZIP code

County (optional)

Primary phone number

Alternate phone number

Email address

Preferred method of contact

Phone

Email

Text

Employment Eligibility

Are you legally authorized to work in the United States?

Yes

No

Will you now or in the future require employer sponsorship for work authorization?

Yes

No

Are you at least 18 years old?

Yes

No

Position Preferences

Employer #1

Company name

Job title

Supervisor name & title

Company address

Phone number

Start date

End date

Starting pay

Ending pay

Job duties & responsibilities

Reason for leaving

Employer #2

Company name

Job title

Supervisor name & title

Company address

Phone number

Start date

End date

Starting pay

Ending pay

Job duties & responsibilities

Reason for leaving

Employer #3

Company name

Job title

Supervisor name & title

Company address

Phone number

Start date

End date

Starting pay

Ending pay

Job duties & responsibilities

Reason for leaving

Education & Training

Highest level of education completed

School name

City & state

Degree / diploma / certificate earned

Field of study

Graduation date (or expected)

Additional Training, Certifications, or Licenses

Certification / license name

Issuing organization

License / certificate number (if applicable)

Expiration date

Skills & Qualifications

Languages spoken (and proficiency level)

Computer / technical skills

Machinery or equipment experience

Other relevant skills

References

Three references required.

Reference #1

Name

Relationship

Company

Phone number

Email address

Reference #2

Name

Relationship

Company

Phone number

Email address

Reference #3

Name

Relationship

Company

Phone number

Email address

Availability

Days available to work

Hours available

Willing to work overtime?

Yes

No

Willing to work weekends?

Yes

No

Transportation

Do you have reliable transportation to and from work?

Yes

No

Criminal History

Optional / when job-related. Convictions will not automatically disqualify you.

Have you ever been convicted of a felony or misdemeanor that has not been sealed or expunged?

Yes

No

If yes, please explain

Voluntary Self-Identification (EEO)

Completion of this section is voluntary and will not affect employment opportunities.

Emergency Contact

Name

Relationship

Phone number

Friends, please fill out this form so we can best serve your needs.

Employment History

Reference #1

Reference #2

Reference #3