* Have you ever applied for employment with us before?

Yes   No

* Have you ever worked for SEIU HCII?

Yes   No

* What is your salary expectation?

* How did you hear about us? If referred, please provide employee’s name.

Please list the names of any relatives working for SEIU:

* When would you be available to begin work?

List Other special training or skills (professional licenses, certificates, languages, computers, etc.):

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School	Name and Location of School	Course of Study	Years Completed	Did you Graduate?	Degree & Major
Graduate				Yes   No
College				Yes   No
Business Trade Technical				Yes   No
High School				Yes   No
Elementary				Yes   No

Give your full employment record, starting with your current or most recent employment

Employer Name & Address	Employer Phone	Dates Employed
Job Title	Supervisor Name & Title
May we Contact?	Responsibilities	Reason for Leaving
Yes   No

Employer Name & Address	Employer Phone	Dates Employed
Job Title	Supervisor Name & Title
May we Contact?	Responsibilities	Reason for Leaving
Yes   No

Employer Name & Address	Employer Phone	Dates Employed
Job Title	Supervisor Name & Title
May we Contact?	Responsibilities	Reason for Leaving
Yes   No

Name	Title	Company	Address	Phone

* Did you serve in the U.S. Armed Forces?

Yes   No

If yes, what branch?

Describe any training received relevant to the position for which you are applying:

* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment.)

Yes   No

* Are you at least 18 years or older?

Yes   No

* Do you know of any reason why you cannot perform the essential functions of the job for which you are applying with or without reasonable accommodation??

Yes   No

I certify that the information provided in this employment application (and accompanying resume, if any) is true and complete, and I understand that any false information or significant omissions may be justification for my dismissal from employment, if discovered at a later date.

I authorize investigation of all statements contained in this application (and accompanying resume, if any). I also authorize the Union to contact my present employer (unless otherwise noted in this application form), past employers, and listed references.

I authorize any person, school, current or previous employer, and organization named in this application form(and accompanying resume, if any) to provide the Union with relevant information and opinion that may be useful to the Union in making a hiring decision, and I release such persons and organizations from any legal liability in making such statements.

* Signature (type name):

* Date: