PIRS Application for Employment
It is the policy of PIRS to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion national origin, or other protected classification.

Name:

Email Address:

Address:     [apt. #]:

City:     State:     Zip Code:

Phone Number: ()-

SSN#:

Are you over 18 years old?

How did you learn of this opening?

Have you been told about essential functions of the job or have you been shown a copy of the job description listing the essential functions of the job?

Can you perform these essential functions with or without reasonable accommodations?

Position applied for? When can you start

EducationSchool & LocationYear
Graduated		MajorDiploma/degree
High School
College/
Unvi.
College/
Unvi.
Grad. School

Are you presently employed? May we contact your employer?

WORK HISTORY (Beginning with most recent or current employer)
Employer's
Name and Address 		Supervisor's
Name & Title:
Telephone #
()- Position:
Start Date: End Date:
Starting Salary: Ending Salary:
Description of
Duties: 		Reason for
Leaving
Employer's
Name and Address 		Supervisor's
Name & Title:
Telephone #
()- Position:
Start Date: End Date:
Starting Salary: Ending Salary:
Description of
Duties: 		Reason for
Leaving
Employer's
Name and Address 		Supervisor's
Name & Title:
Telephone #
()- Position:
Start Date: End Date:
Starting Salary: Ending Salary:
Description of
Duties: 		Reason for
Leaving
Employer's
Name and Address 		Supervisor's
Name & Title:
Telephone #
()- Position:
Start Date: End Date:
Starting Salary: Ending Salary:
Description of
Duties: 		Reason for
Leaving

Have you ever been convicted of a felony?

If yes, please describe circumstances:

In addition to your work history, what other experiences, skills or qualifications do you bring to this position

APPLICANT'S CERTIFICATION AND AGREEMENT

I certify that the facts set forth in this Application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements may result in my dismissal I authorize PIRS to make an investigation of any of the facts set forth in this application.

I understand that employment at PIRS is "at Will", which means that either I or PIRS can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statue. All employment is continued on that basis. I understand that no supervisor, manager or executive of PIRS other than the Executive Director has any authority to alter the foregoing.