Staff Use Only

PIMA COUNTY LIBRARY EMPLOYMENT APPLICATION

PIMA COUNTY ARIZONA @ WORK CAREER CENTERS Date Received______________
nd
320 N Commerce Park Loop 2 Floor, Tucson, AZ 85745
Phone: (520) 724-9649 Fax: (520) 770-4134 EST Class: ________________

Instructions: Please print clearly. Applicant must be 16 & older years of age. Please fill out completely, front and back, use black/blue ink only.
(Must be completed by applicant and does not guarantee eligibility.)
(Resume & last report card if in-school youth is required for screening process and completion of Employment Skills Training Class)
Call 520.724.9649 to schedule your Employment Skills Training Class.

Last Name, First Name, Middle Initial Social Security Number Home Phone Cell Phone
Message Phone Contact Name:
, xxx - xx - Email Address
Date of Birth Age Race/Ethnicity How did you hear about the One
White/Caucasian Hispanic Native American or Native Alaskan Stop Career Center?
African American Asian/Pacific Islander Other______________
Residence Street Address City Zip Code Nearest Major Intersection to home Gender
Male
Female
Mailing Address City Zip Code Are you currently enrolled in WIOA? Yes No
Unsure
Case Manager’s Name

# OF PEOPLE IN HOUSEHOLD: Household income: Under $20,790 $20,791 to $25,665 $25,666 to $30,285 $30,286 to $35,882 Over $35,883
Does your household receive: TANF Food Stamps General Assistance Are you: Foster Child Youth-on-your-own Homeless Live in Group Home

Education Status (Check all that apply) College Grad from School Presently Attending Enrolled in Special Education?
High School/GED Student College Student Yes No IEP? Yes No
High School/GED Graduate HS Dropout/Not Enrolled in School
Do you have any current certifications, licenses, etc? Do you have a résumé? Have you ever completed Employment Skills Training Class?
If so, Describe If so, when?
Yes No Yes No Where?_
Current Grade If not in school, are you Are You Bilingual? Yes No
interested in going back? Besides English,
9th 10th 11th 12th 12 + not in school Yes No What language do you speak, read and/or write?

Do you have a valid AZ driver’s What transportation do you have to and from work? (check all that apply) Have you ever been convicted of a felony?
license? Yes No bus bike own car friend/family none other Yes No

List library or libraries you’re interested in interviewing for? ______________________________________________________________________________

Over
Clerical Skills: (Check all that apply) Multi-Line Phones Fax Filing Copying Sort Mail Typing/Data Entry---

10-Key Customer Service Cashier/Money-handling Schedule Appointments/Meetings Words Per Minute_________________

Computer Skills: Please specify: _______________________________________________________________________________________________________

Other Job Skills AND INTERESTS: Please list any other job skills and interests you have.

When are you available to work? Check all that apply. List hours of availability.

Weekdays ____________________ Weeknights _________________ Weekend days ___________________ Weekend nights ____________________

Part time Other:___________________________________

Employment History (Include Volunteer Jobs) :

Employer: Employer:
Address: Address:
Job Title: Job Title:
Dates of Employment (month/year) From: To: Dates of Employment (month/year) From: To:

Tasks Performed: (Please be specific) Tasks Performed: (Please be specific)

I hereby certify that the information herein is true, and correct to the best of my knowledge. I am aware that should investigation at any time disclose any such misrepresentation
or falsification, my application will be rejected and I may be dismissed from Arizona @ Work Programs. I agree to work cooperatively with staff and to provide pertinent
employment information upon hire and/or discharge. By submitting this application, I certify that I am drug-free and eligible to work in the US.

Name: Date: