EMPLOYMENT / JOB APPLICATION
PERSONAL INFORMATION
FULL NAME: _Logan_______Adam________Chase___________________ DATE:
_9/28/20_________________
First Middle Last
ADDRESS: _19 Railroad Pass__________________________________________
Street Address Apt/Suite
_Cartersville____________________GA__________________30120______________
________
City State Zip Code
E-MAIL: __Loganadamchase02@gmail.com________________________________
PHONE: __706-844-2752___________________
SOCIAL SECURITY NUMBER (SSN): __/___-_/__-__/___
DATE AVAILABLE: ___9/28/20_______________ DESIRED PAY: $_________ ☐ HOUR ☐
SALARY
POSITION APPLIED FOR: __Audio-Visual technician
_______________________________________________
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: _____Cass High School________________ CITY / STATE: __White
Georgia___________________
FROM: ____Aug 8th 2017_________________ TO: ______May 2021_______________
GRADUATE? ☐ YES ☐ NO DIPLOMA: _____________________
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COLLEGE: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
GRADUATE? ☐ YES ☐ NO DEGREE: _____________________
OTHER: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: _____________________
OTHER: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: _____________________
PREVIOUS EMPLOYMENT
EMPLOYER 1: ____Grand Mount Country Church_______________________
Company / Individual
E-MAIL: _Grandmountchurch@bellsouth.net_________________________________
PHONE: ___707-538-5246__________________
ADDRESS: __33 Mason
Road__________________________________________________________
Street Address Apt/Suite
_Calhoun _______________GA________________30130_____________
City State Zip Code
STARTING PAY: $__10_______ ☐ HOUR ☐ SALARY ENDING PAY: $____10_____ ☐ HOUR ☐
SALARY
JOB TITLE: __Church Keeper____________ RESPONSIBILITIES: ___
Clean the church. Get the church ready for events__________________________
FROM: _11/20/19____________________ TO: ______Still Employed
_______________
REASON FOR LEAVING: _______________________________________________________
EMPLOYER 2: __________________________________________________________
Company / Individual
E-MAIL: __________________________________ PHONE: _____________________
ADDRESS: ____________________________________________________________
Street Address Apt/Suite
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____________________________________________________________
City State Zip Code
STARTING PAY: $_________ ☐ HOUR ☐ SALARY ENDING PAY: $_________ ☐ HOUR ☐ SALARY
JOB TITLE: ______________ RESPONSIBILITIES: _____________________________
FROM: _____________________ TO: _____________________
REASON FOR LEAVING: _______________________________________________________
EMPLOYER 3: __________________________________________________________
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: _______________________________________________________
REFERENCES
(PROFESSIONAL ONLY)
FULL NAME: ___Lynn Green____________________________
RELATIONSHIP: __Boss____________
First Last
COMPANY: __Grand Mount Country Church______________________________
TITLE: __owner____________
E-MAIL: ___lynnngreen03@comcast.net_______________________________ PHONE:
___770-556-2395__________________
FULL NAME: __Joey Mosserie _____________________________ RELATIONSHIP:
_Assistant Manager_____________
First Last
COMPANY: _Grand Mount Country Church_______________________________
TITLE: ___Assistant manager ___________
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E-MAIL: _____joemoss66@gmail.com_____________________________ PHONE:
__678-898-2858___________________
FULL NAME: ___Jackson _________Dowers___________________ RELATIONSHIP:
_fellow employee _____________
First Last
COMPANY: ___Grand Mount Country Church_____________________________
TITLE: _Employee_____________
E-MAIL: _JayJayDower@comcast.net_________________________________ PHONE:
_770-800-3346____________________
MILITARY SERVICE
ARE YOU A VETERAN? ☐ YES ☐ NO
BRANCH: _____________________ RANK AT DISCHARGE: _____________________
FROM: _____________________ TO: _____________________
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 ____LOGANCHASE_____________________________ DATE
___9/28/20__________________
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PRINT NAME ____Logan Adam Chase_____________________________
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