Youth Employment Application

Name_______________________________________________

Address_____________________________________________

City, State, Zip _______________________________________

Telephone No. ___________________Cell Phone ________________________

e-mail address _______________________________________

Date of Birth __________________  Grade in School____________

Social Security No. ________________________

Do you have reliable transportation to within 5 miles of your home? _______

Do you receive Special Education Services? ______

If you are 18 years of age, are you registered with the Selective Service? _____

Have you ever been arrested, convicted, in jail or on parole?

EDUCATION/TRAINING BACKGROUND           School Name & Location

______________________________________________________________________________

______________________________________________________________________________

WORK HISTORY  List most recent first.

EMPLOYER NAME____________________________________________________________________

CITY___________________________STATE _______  ZIP_________ PHONE____________________

DATE STARTED ___/___/___   DATE ENDED___/___/___

JOB TITLE_________________________ HOURS PER WEEK ____ HOURLY PAY RATE_________

REASON FOR LEAVING_______________________________________________________________

EMPLOYER NAME ___________________________________________________________________

CITY_____________________________STATE_____  ZIP ________ PHONE_____________________

DATE STARTED___/___/___  DATE ENDED ___/___/___

JOB TITLE________________________  HOURS PER WEEK ___ HOURLY PAY RATE__________

REASON FOR LEAVING_______________________________________________________________

FAMILY INCOME VERIFICATION

Please list ALL family members living with you, INCLUDING yourself, their relationship to you; the type of income (if any) that they earn ( such as wages, unemployment insurance, worker's compensation, child support, FIP, Social Security, etc.); and the amount of income received in the last six months.

I certify that the above information is true to the best of my knowledge and that it is subject to verification.

________________________________                           _____________                   _________________________________

           Signature of Applicant                                                         Date                           Signature of Parent/Guardian

            Include Income                                                                                          Comments: