GENERAL INFORMATION (Please fill out completely or insert “N/A” (Not Applicable)

Last

First

Middle


List your addresses for the past 3 years

Name

full name

Current Address

STREET CITY, STATE ZIP

How Long

months

Previous Address

STREET CITY, STATE ZIP

How Long

months

Previous Address

STREET CITY, STATE ZIP

How Long

months

Home Phone

Cell Phone

Email

Have you been employed at Wiley before?

From:

To:

Availability for work?

Work Type

If necessary, can you work evenings and/or weekends?

Have you ever been convicted of a felony or a violent misdemeanor in the last 7 years? (A conviction will not necessarily bar applicant from employment; do not disclose convictions that have been sealed, expunged, annulled or dismissed)

If yes, please explain:

Can you produce documents to show you are legally eligible to work in the U.S.? (NOTE: any offer of employment is conditioned upon completing form I-9 and providing appropriate documentation)

Position(s) applying for:

Minimum salary expected?

Are you able to perform the essential function(s) of the job(s) applied for either with or without an accommodation?

Describe:

Do you read, speak or write any languages besides English? Please list:


EDUCATION

High School Name

Address

Degree/Diploma

College

Address

Degree/Diploma

Vocational School

Address

Degree/Diploma

Graduate School

Address

Degree/Diploma

List any Certifications

Do you plan to further your education?

Please list any special skills or areas of experience that relate to the position being applied for:

EMPLOYMENT HISTORY

Please list most recent employment first. If more space is needed, you may attach an additional sheet or a resume below.

Employer Name

Street

City

State

Zip

Phone

Reason for Leaving

May we contact this employer:

Date Employed

(from)

Date Employed

(to)

Rate of Pay

start

Rate of Pay

finish

Major Duties:

Supervisor:

Employer 2

Employer Name

Street

City

State

Zip

Phone

Reason for Leaving

May we contact this employer:

Date Employed

(from)

Date Employed

(to)

Rate of Pay

start

Rate of Pay

end

Major Duties:

Supervisor:

Employer 3

Employer Name

Street

State

City

Zip

Phone

Reason for Leaving

May we contact this employer:

Date Employed

(to)

Date Employed

(from)

Rate of Pay

start

Rate of Pay

end

Major Duties:

Supervisor:

Professional References

Name

Occupation

City, State

Phone

Relationship

Name

Occupation

City, State

Phone

Relationship

Name

Occupation

City, State

Phone

Relationship

Name

Occupation

City, State

Phone

Relationship


CERTIFICATION AND AGREEMENT

This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge. I understand that falsification or incompleteness of this information may result in my not being considered for employment or dismissal if I am employed. I authorize the references, former employers and educational institutions listed on this application to give you any and all information concerning my previous employment and/or education achieved they may have, personal or otherwise, and release all parties from all liability for any damages that may result from furnishing any lawful job-related information. I understand that before any offer of employment is extended and/or before actual employment commences, I may be required to submit to a background check as required by the Company. I may also be required to submit to blood, urine, and/or other medical testing for detection of alcohol, drugs, and/or other controlled substances in accordance with Company policies post-offer. Additionally, I may be required by the Company to submit to a postoffer physical examination. Unsatisfactory or inconclusive results of the post-offer examination may necessitate withdrawal of the job offer.

49 CFR §391.23(d) and (e). I understand that I have the right to:

Review information provided by current/previous employers;

Have errors in the information corrected by the previous employers and for those previous employers to re-send the corrected information to the prospective employer; and

Have a rebuttal statement attachment to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.


WE PARTICIPATE IN E-VERIFY

NOTICE: Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. This Security Work Authorization (SWA) will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each applicant’s Form I-9 to confirm work authorization. IMPORTANT: If the Government cannot confirm that you are authorized to work, this SWA is required to provide you written instructions and an opportunity to contact SSA and/or DHS before taking adverse action against you, including terminating your employment SWA and employers may not use E-Verify to re-verify current employees and may not limit or influence the choice of documents presented for use on the Form I-9. If you believe that your SWA has violated its responsibilities under this program or has discriminated against you during the verification process based upon your national origin or citizenship status, please call the Office of Special Counsel for Immigration Related Unfair Employment Practices at 1-800-255-7688 (TDD: 1-800- 237-2515).

SIGNATURE OF APPLICANT

DATE