Test Employee Information This field is hidden when viewing the formName(Required) First Last Telephone(Required)Email(Required) Address(Required) City State / Province / Region Zip/ Postal Code Select countryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth(Required) Month Day Year Marital Status Single Married Divorced U.S. Citizen?(Required) Yes No Issuing State(Required)Driver’s License(Required)Social Security(Required)Position applying for:(Required)Are you able to perform the essential functions of the position?(Required) With accommodations Without accommodations? Work overtime?(Required) Yes No Seeking a permanent position?(Required) Yes No I will be able to report to work (how many days)(Required)days after being notified I am hired.EMPLOYEE HISTORYList most recent employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here, in the summary following this section or on an extra sheet of paper if necessary. No more than 10 years history recommended.Employer Name and Address(Required)Position Title/Duties, Skills(Required)Start Date(Required) MM slash DD slash YYYY End Date(Required) MM slash DD slash YYYY Reason for Leaving(Required)Supervisor(Required)Telephone(Required)Employer Name and Address(Required)Position Title/Duties, Skills(Required)Start Date(Required) MM slash DD slash YYYY End Date(Required) MM slash DD slash YYYY Reason for Leaving(Required)Supervisor(Required)Telephone(Required)EDUCATIONYearsHigh School Collage/Universty Business/Technical AdditionalInstitution NameCompletedField StudyGraduated DegreeInstitution NameCompletedField StudyGraduated DegreeMILITARYAre you a veteran?(Required) Yes No Duity/Specialized TrainingSKILLS & QUALIFICATIONSOther qualifications such as special skills, abilities or honors that should be considered:(Required)Types of computers, software, and other equipment you are qualified to operate or repair:(Required)Professional licenses, certifications or registrations:(Required)Additional skills, including supervision skills, other languages or information regarding the career/occupation you wish to bring to the employer's attention:(Required)In case of accident or illness, please contact:(Required)REFERENCESList two personal references who are not relatives or former supervisors.Name(Required) First Address(Required) Street Address City State / Province / Region Telephone(Required)Occupation(Required)Years Known(Required)Name(Required) First Address(Required) Street Address City State / Province / Region Telephone(Required)Occupation(Required)Years Known(Required)CONTACTIn case of accident or illness, please contact:Name(Required) First Daytime phone(Required)Address(Required) Street Address Address Line 2 City ZIP Code Relationship(Required)INFORMATION TO THE APPLICANTAs part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references. If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms. I understand and agree to the information shown above. Signature (Your typed name is your signature.)(Required)Date(Required) MM slash DD slash YYYY Equal Employment Opportunity: While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment. Developed at employer request by the Alaska Department of Labor & Workforce Development, Employment Security Division.
