APPLICATION FOR EMPLOYMENT

Chronic Solutions
212 West Winesap Road #101
Bothell, WA 98012
Today's Date*

Day
Month
Year
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home*
Cell*
Email*
Are you legally entitled to work in the United States?*
- Yes
- No
Are you 21 years of age or older?*
- Yes
- No
Have you ever been discharged from a previous employer?*
- Yes
- No
If yes, please explain*
Position you are applying for?*
Are you looking for full-time or part-time work?*
Date available to begin work?*
Desired Salary?*
Are you available to work days?*
- Yes
- No
Are you available to work evenings?*
- Yes
- No
Are you available to work weekends?*
- Yes
- No
Are you available to work overtime, if needed?*
- Yes
- No
Are there any dates or times where you are not able to work?*
Skills: (please list all pertinent skills related to the position you are applying for)*
Did you graduate High School or obtain a GED?*
- Yes
- No
If no, what is the highest grade level completed?*
Did you attend College, Trade School, Etc.?*
- Yes
- No
If yes, please provide the following:
Name*
Address*
City State / Province / Region
Dates Attended From*
DD slash MM slash YYYY
Dates Attended To*
DD slash MM slash YYYY
Major*
Did you Graduate?*
- Yes
- No
Please provide the following information for your last 3 employers: (Chronologically, starting with most recent)
Employer Name*
First Last
Employer Address*
Employer Phone*
Supervisor's Name:*
Salary*
Please enter a number from 00001 to 100000.
Job Title*
Job Duties*
Employment Dates From*
DD slash MM slash YYYY
Employment Dates To*
DD slash MM slash YYYY
Reason For Leaving*
May we contact this employer for a reference?*
- Yes
- No
Employer Name*
First Last
Employer Address*
Employer Phone*
Supervisor's Name:*
Salary*
Please enter a number from 00001 to 100000.
Job Title*
Job Duties*
Employment Dates From*
DD slash MM slash YYYY
Employment Dates To*
DD slash MM slash YYYY
Reason For Leaving*
May we contact this employer for a reference?*
- Yes
- No
Employer Name*
First Last
Employer Address*
Employer Phone*
Supervisor's Name:*
Salary*
Please enter a number from 00001 to 100000.
Job Title*
Job Duties*
Employment Dates From*
DD slash MM slash YYYY
Employment Dates To*
DD slash MM slash YYYY
Reason For Leaving*
May we contact this employer for a reference?*
- Yes
- No
Professional References: (people not related to you)
Name*
First Last
Phone*
Relationship*
Years Known*
Name*
First Last
Phone*
Relationship*
Years Known*
Signature:*
Max. file size: 100 MB.
Date:
MM slash DD slash YYYY