APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION DATE MAY 21, 2017

NAME (LAST NAME FIRST) SOCIAL SECURITY NO.
Potvin Joseph
PRESENT ADDRESS CITY STATE ZIP CODE
140 Estates Drive Cambridge Vt 05444
PERMANENT ADDRESS CITY STATE ZIP CODE
Cambridge VT 05444
140 Estates Drive
PHONE NO. REFERRED BY
(802) 644-9302
EMPLOYMENT DESIRED
POSITION DATE YOU CAN START SALARY DESIRED
Licensed Nurse Assistant 5/31/2016 negotiable
ARE YOU IF SO, MAY WE INQUIRE
EMPLOYED? X YES NO WITH YOUR PRESENT EMPLOYER? X YES NO
EVER APPLIED TO WHERE? WHEN?
THIS COMPANY BEFORE? YES NO

EDUCATION HISTORY
YEARS DID YOU
NAME & LOCATION OF SCHOOL SUBJECTS STUDIED
ATTENDED GRADUATE?

Cambridge Elementary School

GRAMMAR SCHOOL 7 yes
Cambridge, Vermont

Lamoille Union High School

HIGH SCHOOL 2 still attending
Hyde Park, Vermont

Human Biology
COLLEGE Community College of Vermont 1 still attending
Medical Terminology
TRADE, BUSINESS OR
Green Mountain Technology and
CORRESPONDANCE 1 still attending Allied Health Careers
SCHOOL Career Center Hyde Park, Vermont

GENERAL INFORMATION
SUBJECTS OF SPECIAL STUDY/RESEARCH
AHA Cpr for Healthcare Providers & First Aid Licensed
WORK OR SPECIAL TRAINING/SKILLS

Nursing Assistant, Personal Care Attendant, Emergency Medical Responder, College

Credit in Medical Terminology and human Biology

U.S. MILITARY OR RANK

NAVAL SERVICE Not at this time.
 FORMER EMPLOYERS (LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)
DATE POSITIO
NAME & ADDRESS OF EMPLOYER SALARY REASON FOR LEAVING
MONTH AND YEAR N
Mountain High Pizza Pie 249 VT-15, Jericho, VT
FROM 9/9/16 $9hr chef
05465
TO current
Bayview Bar And Grill 97 Blakely rd, Colchester, VT
FROM 5/27/16 $10hr chef summer job
05446
TO 10/27/16
Ohavi Zedek, 188 N. Prospect st, burlington VT
FROM 04/2014
05401
TO 08/2015
FROM
TO
Adams 9661 APR 1998 CONTINUED ON OTHER SIDE
 REFERENCES: GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR
YEARS
NAME ADDRESS BUSINESS
KNOWN
Tracy Myers 18 williams ct Jeffersonville, Cambridge Rescue
3
VT 05465
Allied health Careers Instructor,
Beth Weatherbee 738 VT-15 West Hyde Park, VT 05655 Green Mountain Technology and 2
Career Center.

Jeremy Rector 738 VT-15 West Hyde Park, VT 05655 Earth Science/ Physics 3
Teacher
AUTHORIZATION
I certify that the facts contained in this application are true and complete to the best of my knowledge and
understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references and employers listed above to give
you any and all information concerning my previous employment and any pertinent information they may have,
personal or otherwise, and release the company from all liability for any damage that may result from utilization for
such information.
I also understand and agree that no representative of the company has any authority to enter into any agreement
for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in
writing and signed by an authorized company representative.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by
the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

DATE SIGNATURE

INTERVIEWED BY DATE

REMARKS

NEATNESS CHARACTER

PERSONALITY ABILITY

HIRED FOR POSITION WILL SALARY

DEPT. REPORT WAGES
APPROVED: 1. 2. 3.
EMPLOYMENT MANAGER DEPARTMENT HEAD GENERAL MANAGER

This application for employment is sold only for general use throughout the United States. Adams assumes no responsibility and hereby disclaims any liability for the inclusion in this form of any questions
or requests for information upon which a violation of local, state and/or federal law may be based. It is the users responsibility to ensure that this forms use complies with applicable laws which change
from time to time.