Position(s) applied for: Date of application: (mm/dd/yy)

Referral Source: Please Select One Advertisement Employee Relative Government Employment Agency Walk-In Private Employment Agency Other If Other Please Explain:

Name of Source (if applicable):

Name
Last Name: First: Middle:

Address
Street: City: State: Zip Code:

Telephone: Mobile/Beeper/Other Phone:

Social Security Number: Email Address:

If necessary, the best time to call you at home is: AM PM

May we contact you at work? Yes No
If yes, work number and best time to call
Phone Number: Time: AM PM

Have you ever submitted an application to KIRA before? Yes No
If yes, give date: (mm/dd/yy)

Have you ever been employed at KIRA before? Yes No
If yes, give start date: (mm/dd/yy) End Date:

Are you legally eligible for employment in thie country? Yes No
Date available for work: (mm/dd/yy)

Type of Employment Desired:
Full-Time
Part-Time
Temporary
Seasonal

Will you relocate if the job requires it? Yes No

Will you travel if the job requires it? Yes No

Are you able to meet the attendance requirements of this position? Yes No

Will you work over time if required? Yes No
If no, please explain:

Have you ever been bonded? Yes No

Have you been convicted of a crime in the last seven (7) years? Yes No
If yes, please explain:
Conviction will not necessarily be a bar to employment. Each instance and explanation will be considered in relation to the position for which you are applying.

Driver's licesnse number if driving is an essential job function:
State: Number:

Employment History

Provide the following information for your past and current employers, starting with the most recent.
Explain any gaps in employment in comments section below.

Employer One:
Employer: Telephone:
Address:
Job Title:
Immediate Supervisor: Title:
May we contact for reference? Yes No Later
Dates Employed: (mm/dd/yy) From: To:
Hourly Rates / Salary Starting: $ per
Hourly Rates / Salary Final: $ per
Summarize the type of work performed and job responsibilities:

Reason for Leaving:

Employer Two:
Employer: Telephone:
Address:
Job Title:
Immediate Supervisor: Title:
May we contact for reference? Yes No Later
Dates Employed: (mm/dd/yy) From: To:
Hourly Rates / Salary Starting: $ per
Hourly Rates / Salary Final: $ per
Summarize the type of work performed and job responsibilities:

Reason for Leaving:

Employer Three:
Employer: Telephone:
Address:
Job Title:
Immediate Supervisor: Title:
May we contact for reference? Yes No Later
Dates Employed: (mm/dd/yy) From: To:
Hourly Rates / Salary Starting: $ per
Hourly Rates / Salary Final: $ per
Summarize the type of work performed and job responsibilities:

Reason for Leaving:

Employer Four:
Employer: Telephone:
Address:
Job Title:
Immediate Supervisor: Title:
May we contact for reference? Yes No Later
Dates Employed: (mm/dd/yy) From: To:
Hourly Rates / Salary Starting: $ per
Hourly Rates / Salary Final: $ per
Summarize the type of work performed and job responsibilities:

Reason for Leaving:

Comments: (Including explantion of any gaps in employment)

Skills and Qualifications: (Summarize any special training, skills, licenses and/or certificates that may qualitfy you as being able to perform job-related fucntions for which you are applying)

Educational Background

A . List last (3) schools attended, starting with most recent. B . List number of years completed. C . Indicate degree or
diploma earned, if any. D . Grade Point Average or Class Rank. E . Major field of study. F . Minor field of study (if applicable).

1 - School One
Name: Years Completed: Degree/Diploma:
GPA / Class Rank: Major: Minor:

2 - School Two
Name: Years Completed: Degree/Diploma:
GPA / Class Rank: Major: Minor:

3 - School Three
Name: Years Completed: Degree/Diploma:
GPA / Class Rank: Major: Minor:

References

List names and telephone numbers of three business/work references who are not related to you and are not
previous supervisors. If not applicable, list three schools or personal references who are not related to you.

1 - Reference One
Name: Years Known: Telephone:

2 - Reference Two
Name: Years Known: Telephone:

3 - Reference Three
Name: Years Known: Telephone:

Additional Information

List professional, trade, business, or civic associations and any offices held.
EXCLUDE MEMBERSHIPS WHICH WOULD REVEAL SEX, RACE, RELIGION, NATIONAL ORIGIN, AGE, COLOR, DISABILITY, UNION MEMBERSHIP OR AFFILIATION , OR ANY OTHER SIMILARLY PROTECTED STATUS.

Organization: Offices Held:

Organization: Offices Held:

Organization: Offices Held:

Organization: Offices Held:

List special accomplishments, publications, awards, etc.
EXCLUDE MEMBERSHIPS WHICH WOULD REVEAL SEX, RACE, RELIGION, NATIONAL ORIGIN, AGE, COLOR, DISABILITY, UNION MEMBERSHIP OR AFFILIATION , OR ANY OTHER SIMILARLY PROTECTED STATUS.

List any additional information you would like us to consider:

If you would like to submit a resume please forward it to applykira@fortcarsonsupportservices.com

TERMS AND CONDITIONS

I understand that if I am employed, any misrepresentations or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer's service, whenever it is discovered

I give the employer the right to contact and obtain information from all references, employers, and educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering, and using such information and all other persons, corporations or organizations for furnishing such information.

The employer does not lawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, if will be necessary to fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer.

I understand it is this company's policy not to refuse to hire a qualified individual with a disability because of that person's need for reasonable accommodation as required by the ADA .

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

I represent and warrant that I have read and fully understand the foregoing, including all instructions oral or in this application and seek employment under these conditions.

I acknowledge that I have read and understand these terms and conditions