<p> Employment Assistance Application</p><p>Program: ______Grad Date: ______Social Security Number: ______Name:______Home Address: ______City:______State: ______Zip Code:______Phone: ______Alternate Phone:______Email: ______List references (name and phone number) 1. ______4. ______2. ______5. ______3. ______6. ______List any special skills, other languages you speak, certifications, licenses, or training you have had. Include college, military, and trade schools: ______Type of work desired (salary, location, environment, hours):______</p><p>Current Employment Status Employed: ____ Unemployed: ___ Full Time: ____ Part Time: ____ is this position related to your field? ______</p><p>Employer: ______Type of business: ______</p><p>Employer’s Address: ______</p><p>Employer’s Phone:______Fax:______Supervisor’s name :______Date of Hire: ______Pay Rate: ______</p><p>Duties:______</p><p>Do you have a driver’s license?______# of points:____ Source of transportation:______Have you ever been convicted of any crime other than a minor traffic violation?______If so explain: ______</p><p>Sign ONE of the following statements: 1. I request further employment assistance and authorize the school to discuss the information provided with prospective employers. I also hereby give the school permission to release any and all requested information to prospective employers including, but not limited to, my attendance and GPA. Further, I hereby give permission to verify my employment and salary, and post my employment information at the school.</p><p>______Signature Date</p><p>2. I decline further employment assistance at this time with the understanding that this assistance will be available to me at my request.</p><p>______Signature Date</p><p>Reasons for declination: Further Education ___ Military ___ Medical ___ Foreign Student ___ Incarceration ___</p><p>Other (Please explain): ______</p><p>Signature confirming approval (School Director) ______</p>