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