EMPLOYMENT / JOB APPLICATION
PERSONAL INFORMATION
FULL NAME: _Madison____Dawn_______Strickland_____________ DATE: _3/5/2021
First Middle Last
ADDRESS: _23 Cheryl Dr _________________________________________
Street Address Apt/Suite
Cartersville__________________GA__________30121__________________
City State Zip Code
E-MAIL: _Madison Strickland1103@gmail.com___________ PHONE: _678-767-6657_
SOCIAL SECURITY NUMBER (SSN): _____-____-_____
DATE AVAILABLE: _3/6/2021____________DESIRED PAY: $_9.00________ ☐ HOUR ☐
SALARY
POSITION APPLIED FOR: _Dental Hyginist_______________________________
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____________________ CITY / STATE: _White,Ga______
FROM: __2017___________________ TO: ____2021_________________
GRADUATE? ☐ YES ☐ NO DIPLOMA: _____________________
COLLEGE: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
GRADUATE? ☐ YES ☐ NO DEGREE: _____________________
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OTHER: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: _____________________
OTHER: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: _____________________
PREVIOUS EMPLOYMENT
EMPLOYER 1: __________________________________________________________
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 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: __________________________________________________________
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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: _Pam___________Winters___________________ RELATIONSHIP: Boss_
First Last
COMPANY: _Love them dogs_______________________________ TITLE:
E-MAIL: __________________________________ PHONE: _678-231-8207_
FULL NAME: _Jane ____________Woods__________________ RELATIONSHIP: Boss
First Last
COMPANY: _The cutting Edge_______________________________ TITLE: _____
E-MAIL: __________________________________ PHONE: _770-314-1623_____
FULL NAME: _Katina____________Jones__________________ RELATIONSHIP: Boss_
First Last
COMPANY: ________________________________ TITLE: _Babysitting_____________
E-MAIL: __________________________________ PHONE: _770-728-3298________
MILITARY SERVICE
ARE YOU A VETERAN? ☐ YES ☐ NO
BRANCH: _____________________ RANK AT DISCHARGE: _____________________
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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 _________________________________ DATE __3-5-2021______
PRINT NAME _Madison Strickland________________________________
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