Name: Jimmie Hale Mission
Address: P.O. Box 10472, Birmingham, AL, 35202, US
Telephone: (205) 323-5878

Job Application Form

Step 1 of 4

POSITION INFORMATION
Application Date:*
MM slash DD slash YYYY
Position Location
Where is the position located?
Position Title

List the title of the position from the job posting.
CONTACT INFORMATION
Last Name:*
First Name:*
Middle Initial:
Street Address:*
City:*
State:*
ZIP Code:*
Home Phone:
Work Phone:
Cell Phone:
Email Address:
EDUCATION
High School Name or GED:
From Date:

mm/yyyy
To Date:

mm/yyyy
College:
From Date:

mm/yyyy
To Date:

mm/yyyy
Major:
Minor:
Degree(s) Earned:
College:
From Date:

mm/yyyy
To Date:

mm/yyyy
Major:
Minor:
Degree(s) Earned:
College:
From Date:

mm/yyyy
To Date:

mm/yyyy
Major:
Minor:
Degree(s) Earned:
Other (specify):
From Date:

mm/yyyy
To Date:

mm/yyyy
Major:
Minor:
Degree(s) Earned:

ACHIEVEMENTS
List any skills, awards, certificates, licenses or professional achievements:
REFERENCES
Please list three references, other than relatives, who can provide information verifying qualifications, character or experience:
Name and Title:
Address:
Phone Number:
Name and Title:
Address:
Phone Number:
Name and Title:
Address:
Phone Number:
FAMILY RELATIONSHIPS
For the purposes of disclosure, relative includes the following: spouse, dependent, adult child and his or her spouse, parent, spouse's parents, sibling and his or her spouse.
Are you a relative of any employee of the Jimmie Hale Mission?*
- Yes
- No
List the name(s), relationship and employer/position of all relative(s):
CONSENT AGREEMENT:
I represent and warrant that the information I have given on this application is complete and true to the best of my knowledge and belief. I further acknowledge that I understand that I must provide documented verification of education, experience and required certifications and/or licensures. I represent and warrant that I have answered fully and truthfully all questions regarding criminal convictions/records. I understand that any offer of employment is contingent upon a satisfactory criminal background investigation and negative drug and alcohol screen test. I hereby authorize The Jimmie Hale Mission and/or its assignee to conduct a criminal background history investigation and drug and alcohol screen test. I understand that in the event a conviction for a felony or any crime involving moral turpitude is found that termination of employment may occur. I understand and agree that my employment will terminate in the event of a positive drug/alcohol screen test. I authorize any testing agency to provide the results of the drug screen test to The Jimmie Hale Mission. I hereby expressly request, and give permission to former employers and any persons who may have pertinent information concerning this application to furnish such information to The Jimmie Hale Mission human resource appointee. I agree to hold such persons harmless, and I do hereby release them from any and all liability for damage of any nature whatsoever for furnishing such information. I understand that failure to provide full and true information on this application may result in disqualification or dismissal.
Signature:*

Typing your name in this blank will server as your digital signature for the above consent agreement
Date of Signature:*
MM slash DD slash YYYY

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Job Application Form

Step 1 of 4

POSITION INFORMATION

CONTACT INFORMATION

EDUCATION

EMPLOYMENT HISTORY

ACHIEVEMENTS

REFERENCES

FAMILY RELATIONSHIPS

CONSENT AGREEMENT: