ALPHA-BITS LEARNING CENTER 227 Londonderry Turnpike Manchester, NH 03103 603-624-6650

Employment Application

Applicant Information

Full Name:	Date:
First	Last/Maiden	M.I.

Address:
Street Address	DATE OF BIRTH

City	State	ZIP Code

Phone:	Cell #l

Date Available:	Social Security No.:

Position Applied for

Days/Hours Avail.	M	T	W	TH	FR

Have you ever worked for this company?	YES	NO	If yes, when?

Have you ever been convicted of a felony?	YES	NO

If yes, explain:

Education

High School:	Address:

From:	To:	Did you graduate?	YES	NO	Diploma::

College	E.C.E. Credits:	YES NO If yes, how many?

From:	To:	Did you graduate?	YES	NO	Degree:

Other:	Address:

From:	To:	Did you graduate?	YES	NO	Degree:

References

Please list three professional references.

Full Name:	Relationship:
Company:	Phone:
Address:
Full Name:	Relationship:
Company:	Phone:
Address:
Full Name:	Relationship:
Company:	Phone:
Address:

Previous Employment

Company:	Phone:
Address:	Supervisor:

Job Title:	Starting Salary:	$	Ending Salary:	$

Responsibilities:

From:	To:	Reason for Leaving:

May we contact your previous supervisor for a reference?	YES	NO

Company:	Phone:
Address:	Supervisor:

Job Title:	Starting Salary:	$	Ending Salary:	$

Responsibilities:

From:	To:	Reason for Leaving:

May we contact your previous supervisor for a reference?	YES	NO

Disclaimer and Signature

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature:	Date: