EMPLOYMENT / JOB APPLICATION
PERSONAL INFORMATION
FULL NAME: Haley Marie Smith DATE: 9-28-2020
First Middle Last
ADDRESS: 40 Spring Ridge Rd NW
Street Address Apt/Suite
Kingston GA 30145
City State Zip Code
SOCIAL SECURITY NUMBER (SSN): 667-20-8657
DATE AVAILABLE: 10-1-2020 DESIRED PAY: $35,000 ☐ HOUR ☐ SALARY
POSITION APPLIED FOR: Phlebotomist
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, GA
FROM: 2017 TO: Present
GRADUATE? ☐ YES ☐ NO DIPLOMA: (graduate in 2021)
COLLEGE: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
GRADUATE? ☐ YES ☐ NO DEGREE: _____________________
OTHER: Bartow County College and Career Academy
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CITY / STATE: Cartersville, GA
FROM: 2019 TO: Present
DEGREE/CERTIFICATION: Phlebotomy Certification
OTHER: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: _____________________
PREVIOUS EMPLOYMENT
EMPLOYER 1: Pettit Creek Farms
Company / Individual
E-MAIL: __________________________________ PHONE: (770) 386-8688
ADDRESS: 337 Cassville Rd
Street Address Apt/Suite
Cartersville GA 30120
City State Zip Code
STARTING PAY: $8.00 ☐ HOUR ☐ SALARY ENDING PAY: $9.00 ☐ HOUR ☐ SALARY
JOB TITLE: Farmhand RESPONSIBILITIES: Take care of animals, entertain customers,
prepare party field
FROM: 2017 TO: Present
REASON FOR LEAVING: Ready to begin my career as a phlebotomist
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: _______________________________________________________
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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: Kayla Jackson RELATIONSHIP: Supervisor
First Last
COMPANY: Cass High School TITLE: Media Specialist
FULL NAME: Harry Wyche RELATIONSHIP: Teacher
First Last
COMPANY: Bartow County College and Career Academy TITLE: Teacher
FULL NAME: Candace Hillhouse RELATIONSHIP: Supervisor
First Last
COMPANY: Pettit Creek Farms TITLE: Manager
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 9-28-2020
PRINT NAME Haley Smith
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