Employment Application for Potomac Center
Email address *
Personal Information
Please provide the necessary personal information required below.
Application Date *
MM
/
DD
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YYYY
First Name *
Your answer
Last Name *
Your answer
Position Applying For *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
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Phone Number *
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County *
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How long have you lived at your current address?
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Have you ever filed an application with us before?
If yes, please provide date of application submission.
Your answer
Have you ever been employed with us before?
If yes, please provide date of employment.
Do you have any relatives working at Potomac Center?
If yes, please provide name of person and relationship.
Your answer
May we contact your present employer?
On what date would you be available for work?
Your answer
Are you prevented from lawfully becoming employed in this country because of Visa or immigration? (Proof of citizenship or immigration status will be required upon employment.)
Please select when you are available to work:
Full Time
Part Time
Temporary
Shift 1
Shift 2
Shift 3
Row 1
Are you currently on "lay-off" status and subject to recall?
Can you travel if a job requires it?
Have you ever been convicted of a felony within the last ten years? (Conviction will not necessarily disqualify an applicant.)
If yes, please provide date of conviction.
Your answer
Educational Information
Please provide the necessary educational information required below.
High School Name/Location
Your answer
Diploma/Degree
Your answer
Describe course of study
Your answer
Undergraduate College/University
Your answer
Diploma/Degree
Your answer
Describe course of study
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Graduate/Professional
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Diploma/Degree
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Describe course of study
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Describe any specialized training, apprenticeship, skills and extracurricular activities.
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Describe any honors you have received.
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State any additional information that you feel may be helpful to us in considering your application.
Your answer
List professional, trade, or business activities and offices held.
Your answer
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