Apply For Employment

*Required Fields

SureSource LLC. Application for Employment

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department. We are an equal opportunity employer actively supporting workplace diversity. Employment decisions are based on merit, qualifications, and abilities. We do not discriminate in employment opportunities or practices on the basis of race, color, religion, sex or sexual orientation, national origin, age, disability, or any other characteristic protected under law. As part of our commitment to a safe work environment, SureSource conducts pre-employment drug testing.

*Position Desired:
*Last Name:
*First Name:
*Street Address:
Additional Address:
*City:
*State:		Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Outside of US
*Zip Code:
Social Security Number:
*Primary Phone Number:		Ext:
Secondary Phone Number:		Ext:
Email Address:
*How did you hear about us/the position you are applying for?
Newspaper (which one?) Self Referral State Job Service Internet Site (which one?) Employee Referral (name) Other (please explain)
*Are you 18 years of age or older?		Yes No
If not 18, can you furnish a work permit?		Yes No
*Have you ever been employed here?		Yes No
If Yes, dates of previous employment:		Month January February March April May June July August September October November December Year 2000 2001 2002 2003 2004 2005 2006 2007 2008
Previous position title:
*Are you legally eligible for employment in this country? Yes No
Date available for work:		Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
What is your desired salary:		$ per Choose Hour Year
*Type of employment desired:
		Full-time
		Part-time
		Seasonal
		Internship/Coop
*Do you have any restrictions that, without reasonable accommodation, would prevent you from fulfilling the essential functions of the job applied for? (Essential Function Capabilities disclosure available upon
request) Yes No
If yes, provide details:
Employment History Please complete ALL sections beginning with your most recent employment/assignment/volunteer activity. Do NOT complete this section by entering “see resume”. (Your resume cannot be considered a part of this legal hiring document.)
*Employer Name:
*Employer Street Address:
Additional Employer Street Address:
*Employer City:
*Employer State:		Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Outside of US
Employer Zip Code:
*Employer Phone Number:		Ext:
*Immediate Supervisor:
*May we contact for a reference?:		Yes No Later
*Dates of Employment: From:		Month January February March April May June July August September October November December Year 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
*Dates of Employment: To:		Month present January February March April May June July August September October November December Year 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
*Final Job Title:
*Final/Current Salary:		$ per Choose Hour Year
*Reason for leaving?:
*Summarize the nature of work performed/job responsibilities:
Employer Name:
Employer Street Address:
Additional Employer Street Address:
Employer City:
Employer State:		Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Outside of US
Employer Zip Code:
Employer Phone Number:		Ext:
Immediate Supervisor:
May we contact for a reference?:		Yes No Later
Dates of Employment: From:		Month January February March April May June July August September October November December Year 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Dates of Employment: To:		Month January February March April May June July August September October November December Year 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Final Job Title:
Final Salary:		$ per Choose Hour Year
Reason for leaving?:
Summarize the nature of work performed/job responsibilities:
Employer Name:
Employer Street Address:
Additional Employer Street Address:
Employer City:
Employer State:		Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Outside of US
Employer Zip Code:
Employer Phone Number:		Ext:
Immediate Supervisor:
May we contact for a reference?:		Yes No Later
Dates of Employment: From:		Month Month January February March April May June July August September October November December Year 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Dates of Employment: To:		Month January February March April May June July August September October November December Year 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Final Job Title:
Final Salary:		$ per Choose Hour Year
Reason for leaving?:
Summarize the nature of work performed/job responsibilities:
Summarize any training, skills, licenses and/or certifications that may qualify you as being able to perform job related functions in the position for which you are applying.