Employment Application Step 1 of 3 33% CrossWinds is an equal opportunity employer. CrossWinds will not discriminate unlawfully against any employee or applicant based on race, color, national origin, sex, religion, age, disability, veteran status, or any other unlawful reason. Directions: Please print and use black or blue ink or responses may be typed. Please attach a separate sheet if there is not sufficient space for responses. If a question does not apply to you, please write NA after the question. Applications are not guaranteed to be considered for other positions that become available later. If you need an accommodation in order to complete the application, please contact Human Resources.Applicant InformationName First Middle Last Address Street Address Address Line 2 City State ZIP / Postal Code PhoneEmail Date Available for HireMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Position applying for:What influenced you to apply for employment with CrossWinds?AdvertisementWalk InEmployment AgencyEmployee ReferralPlease Name EmployeeHave you ever interviewed with CrossWinds before?YesNoIf yes, list date(s) and job title(s)Have you ever been employed by CrossWinds before?YesNoIf yes, list date(s) and job title(s)Do you have any relatives employed by CrossWinds?YesNoIf yes, list name(s) and job title(s)EducationCheck Highest Grade Completed: High School 9 10 11 12 Check Highest Grade Completed: College, Trade, or Business 1 2 3 4 Graduate StudiesHigh School Name of School Address Major Studies Degree/Cert. Earned College/University Name of School Address Major Studies Degree/Cert. Earned Vocational, Business, Other Name of High School Address Major Studies Degree/Cert. Earned List Applicable Licenses, Certifications, or Professional Designations: (Those that reveal race, religious affiliation, age, or other protected status need not be listed.)Other Special Knowledge, Qualifications, or Language SkillsList Computer Knowledge and Skills Employment History List all employment for the past 10 years, starting with the most recent position. All information must be completed. You may attach a resume, but not in place of completing this form. Use additional sheets if necessary.Previous Employer 1 Company Address Phone Supervisor Job Title Dates Employed From To Salary Starting Salary $ Ending Salary $ Reason for LeavingDuties & ResponsibilitiesPrevious Employer 2 Company Address Phone Supervisor Job Title Dates Employed From To Salary Starting Salary $ Ending Salary $ Reason for LeavingDuties & ResponsibilitiesPrevious Employer 3 Company Address Phone Supervisor Job Title Dates Employed From To Salary Starting Salary $ Ending Salary $ Reason for LeavingDuties & ResponsibilitiesPrevious Employer 4 Company Address Phone Supervisor Job Title Dates Employed From To Salary Starting Salary $ Ending Salary $ Reason for LeavingDuties & ResponsibilitiesGeneral Are you at least 18 years old?YesNoMay we contact your current employer for references?YesNoWill you be able to perform the essential job duties of the position you are applying for with or without reasonable accommodation?YesNoAre you legally eligible for employment in the United States?YesNoHave you ever been convicted of a crime, which has not been annulled, expunged, or sealed by a court? (A response of yes does not automatically disqualify your application.)YesNoIf yes, please explain:ReferencesList the following information for a minimum of three references not related to you. All information must be completed. Use additional sheets if necessary..Reference 1 Reference Name Relationship Telephone Number Years Known Reference 2 Reference Name Relationship Telephone Number Years Known Reference 3 Reference Name Relationship Telephone Number Years Known Certification & AuthorizationCERTIFICATION & AUTHORIZATION I certify that the above information is true, correct, and complete. I understand that the submission of any false or misleading information or the failure to provide any information herein requested may result in the rejection of my application, or in the event of my employment with CrossWinds, may result in my dismissal. I authorize CrossWinds to inquire into my educational and past employment history as needed to research my qualifications for this position, including information disclosed in this application, a submitted resume, or in personal interviews. I give consent to any current or former employer to provide employment-related information about me to CrossWinds and will hold the agency and my current or former employer harmless for providing employment information or for any employment decision made based on such information. This application will expire in 30 days. After that date, unless otherwise notified, I understand that my status as an applicant will end. I may re-apply for employment in the future by completing a new application. I understand that this employment application or the granting of an interview is not a contract of employment between myself and CrossWinds. I further agree that, if hired, my employment will be terminable at will and may be terminated by me or CrossWinds at any time and for any reason. I understand that CrossWinds is a Drug-Free Workplace and, if hired, I agree to abide by the rules set forth in this policy. In the event of my employment, I will be required to provide original documents that verify my identity and right to work in the United States under the Immigration Reform and Control Act of 1986. The document(s) provided will be used for completion of Form I-9. I will also be required to complete background screening forms in order for CrossWinds to obtain my criminal history record, two abuse and neglect screenings, and a motor vehicle history record. I hereby acknowledge that I have read and agree to the above statements.I certify that the above is true and correct.* Name Date Please upload your resume and cover letter as a Word Document or PDF. 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