EMPLOYMENT / JOB APPLICATION
PERSONAL INFORMATION
FULL NAME: Sha’Diamond Alexis Nelson DATE: September 28, 2020
First Middle Last
ADDRESS: 321 Arapaho Dr
Street Address Apt/Suite
Acworth GA 30102
City State Zip Code
E-MAIL: Diamondnelson8@yahoo.com PHONE: (678)542-0817
SOCIAL SECURITY NUMBER (SSN): 654-14-8023
DATE AVAILABLE: __________________ DESIRED PAY: $18.00 ☐ HOUR ☐ SALARY
POSITION APPLIED FOR: Phlebotomist
EMPLOYMENT DESIRED: ☐ FULL-TIME ☐ PART-TIME ☐ SEASONAL
EMPLOYMENT ELIGIBILITY
ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S? ☐ YES ☐ NO*
HAVE YOU EVER WORKED FOR THIS EMPLOYER? ☐ YES* ☐ NO
*IF YES, WRITE THE START AND END DATES: ____________________________________
HAVE YOU EVER BEEN CONVICTED OF A FELONY? ☐ YES* ☐ NO
*IF YES, PLEASE EXPLAIN: ____________________________________________________
EDUCATION
HIGH SCHOOL: Woodland High School CITY / STATE: Cartersville, Georgia
FROM: August 5, 2016 TO: December 2020
GRADUATE? ☐ YES DIPLOMA:
COLLEGE: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
GRADUATE? ☐ YES ☐ NO DEGREE: _____________________
OTHER: _____________________ CITY / STATE: _____________________
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FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: _____________________
OTHER: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: _____________________
PREVIOUS EMPLOYMENT
EMPLOYER 1: Zaxbys
Company / Individual
E-MAIL: __________________________________ PHONE: _____________________
ADDRESS: ____________________________________________________________
Street Address Apt/Suite
____________________________________________________________
City State Zip Code
STARTING PAY: $9.50 ☐ HOUR ENDING PAY: $_________ ☐ HOUR ☐ SALARY
JOB TITLE: Cashier RESPONSIBILITIES: taking orders and counting money
FROM: September 16, 2017 TO: September 3, 2020
REASON FOR LEAVING: Better opportunity
EMPLOYER 2: __________________________________________________________
Company / Individual
E-MAIL: __________________________________ PHONE: _____________________
ADDRESS: ____________________________________________________________
Street Address Apt/Suite
____________________________________________________________
City State Zip Code
STARTING PAY: $_________ ☐ HOUR ☐ SALARY ENDING PAY: $_________ ☐ HOUR ☐ SALARY
JOB TITLE: ______________ RESPONSIBILITIES: _____________________________
FROM: _____________________ TO: _____________________
REASON FOR LEAVING: _______________________________________________________
EMPLOYER 3: __________________________________________________________
Company / Individual
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E-MAIL: __________________________________ PHONE: _____________________
ADDRESS: ____________________________________________________________
Street Address Apt/Suite
____________________________________________________________
City State Zip Code
STARTING PAY: $_________ ☐ HOUR ☐ SALARY ENDING PAY: $_________ ☐ HOUR ☐ SALARY
JOB TITLE: ______________ RESPONSIBILITIES: _____________________________
FROM: _____________________ TO: _____________________
REASON FOR LEAVING: _______________________________________________________
REFERENCES
(PROFESSIONAL ONLY)
FULL NAME: Gabby Dely RELATIONSHIP: Aunt
First Last
COMPANY: Discount Truck Tires and Towing TITLE:
E-MAIL: __________________________________ PHONE: _____________________
FULL NAME: __________________ RELATIONSHIP: ______________
First Last
COMPANY: ________________________________ TITLE: ______________
E-MAIL: __________________________________ PHONE: _____________________
FULL NAME: _______________________________ RELATIONSHIP: ______________
First Last
COMPANY: ________________________________ TITLE: ______________
E-MAIL: __________________________________ PHONE: _____________________
MILITARY SERVICE
ARE YOU A VETERAN? ☐ NO
BRANCH: _____________________ RANK AT DISCHARGE: _____________________
FROM: _____________________ TO: _____________________
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TYPE OF DISCHARGE: _____________________
IF NOT HONORABLE, PLEASE EXPLAIN: ______________________________________
BACKGROUND CHECK CONSENT
IF ASKED, ARE YOU WILLING TO CONSENT TO A BACKGROUND CHECK? ☐ YES ☐ NO
DISCLAIMER
Applicant understands that this is an Equal Opportunity Employer and committed to excellence
through diversity. In order to ensure this application is acceptable, please print or type with the
application being fully completed in order for it to be considered.
Please complete each section EVEN IF you decide to attach a resume.
I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this
application leads to my eventual employment, I understand that any false or misleading
information in my application or interview may result in my employment being terminated.
SIGNATURE Sha’Diamond Nelson DATE 11/19/2020
PRINT NAME Sha’Diamond Nelson
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