Employment Form

Fields marked with an * are required

KANSASWORKS Job Order #

Applicant Information

Full Name*

Email*

Date

Open the calendar popup.

Address*

City*

State*

Zip

Phone*

Alt Phone

Date Available*

Open the calendar popup.

Position Applied for*

Are you a citizen of the United States?*

Yes

If no, are you authorized to work in the U.S.?

Yes

Have you ever worked for this company?*

If yes, when?

Have you ever been convicted of a felony?*

If yes, explain:

Education

High School

High School Address

From (high school)

Open the calendar popup.

To (high school)

Open the calendar popup.

Did you graduate high school?

Yes

Degree

College

College Address

From (college)

Open the calendar popup.

To (college)

Open the calendar popup.

Did you graduate college?

Yes

College Degree

Other

Other Address

From (other)

Open the calendar popup.

To (other)

Open the calendar popup.

Did you graduate?

Yes

Previous Employment

Company #1

Company #1 Phone

Company #1 Address

Company #1 City

Company #1 State

Company #1 Zip Code

Company #1 Job Title

Company #1 Responsibilities

Company #1 Starting Salary

Company #1 Ending Salary

Company #1 Start Date

Open the calendar popup.

Company #1 End Date

Open the calendar popup.

Company #1 Reason for Leaving

Company #1 Supervisor

May we contact your Company #1 supervisor for a reference?

Yes

Previous Employment Continued

Company #2

Company #2 Phone

Company #2 Address

Company #2 City

Company #2 State

Company #2 Zip Code

Company #2 Job Title

Company #2 Responsibilities

Company #2 Starting Salary

Company #2 Ending Salary

Company #2 Start Date

Open the calendar popup.

Company #2 End Date

Open the calendar popup.

Company #2 Reason for Leaving

Company #2 Supervisor

May we contact your Company #2 supervisor for a reference?

Company #3

Company #3 Phone

Company #3 Address

Company #3 City

Company #3 State

Company #3 Zip Code

Company #3 Job Title

Company #3 Responsibilities

Company #3 Starting Salary

Company #3 Ending Salary

Company #3 Start Date

Company #3 End Date

Company #3 Reason for Leaving

Company #3 Supervisor

May we contact your Company #3 supervisor for a reference?

Yes

Military Service

Branch

From

Open the calendar popup.

Rank at Discharge

Type of Discharge

If other than honorable, explain:

Upload Cover Letter

Upload a Resume

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.*

I Agree

Today's Date*

Open the calendar popup.

The code you entered is not valid.

Type the code from the image