1. We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, religion, disability, sex (including pregnancy), sexual orientation, gender identity, veteran’s status or national origin.

    

   I. Personal Information

2. Your Name *
3. Email Address *
4. Las 4 of SSN *
5. Address *
6. Phone Number *

All persons hired must submit satisfactory proof of employment authorization and identity (valid driver's license, birth certificate, Green Card, etc.) within three days of being hired. Failure to submit such proof within the required time shall result in immediate employment termination.

1. Position Applied For * —Please choose an option—NewsletterNewspaperFriendRelativeOther
2. 1. Is there any information we would need about your name or use of another name for us to be able to check your work record? * YesNo
3. If Yes please explain:
4. 2. Do you have any relatives or friends who are presently (or have formerly been) employed by Nevada PEP? * YesNo
5. If Yes please explain:
6. 3. How were you referred to Nevada PEP? —Please choose an option—NewsletterNewspaperFriendRelativeOther
7. If Other please explain:
8. 4. Have you ever been convicted of a felony? * YesNo
9. If Yes please explain:
10. 5. Do you read, write or speak a foreign language? * YesNo
11. If Yes, what language:

12. II. Educational History

    For each entry, please provide: School Name, Location, Years Completed, and Degree/Diploma

13. Elementary School
14. Junior/Middle School
15. High School
16. High School
17. College

18. III. Employment History

    Please include all employment for the last five years.

19. Company Name (Most Recent)
20. Position Held
21. Dates Employed (From/To)
22. Address
23. Monthly Wage/Salary
24. Manager/Supervisor
25. Telephone
26. Reason for leaving

27. ___

28. Company Name
29. Position Held
30. Dates Employed (From/To)
31. Address
32. Monthly Wage/Salary
33. Manager/Supervisor
34. Telephone
35. Reason for leaving

36. ___

37. Company Name
38. Position Held
39. Dates Employed (From/To)
40. Address
41. Monthly Wage/Salary
42. Manager/Supervisor
43. Telephone
44. Reason for leaving

45. ___

46. Company Name
47. Position Held
48. Dates Employed (From/To)
49. Address
50. Monthly Wage/Salary
51. Manager/Supervisor
52. Telephone
53. Reason for leaving

54. ___

55. Company Name
56. Position Held
57. Dates Employed (From/To)
58. Address
59. Monthly Wage/Salary
60. Manager/Supervisor
61. Telephone
62. Reason for leaving

63. ___

64. NOTE: We may contact all of the employers listed, unless you specifically exclude them below. Please list any employers you do not want us to contact and your reason for the exclusion:

65. IV. References