KEENE STATE COLLEGE
DEPARTMENT OF CAMPUS SAFETY
229 MAIN ST., KEENE, NH 03435
Employment History – Please list most recent position first
Company/Organization: _______________________________________________________________
Address: _______________________________________ City: ____________________State: ______
Supervisor Name and Position: _____________________________Telephone #: _________________
Position Title: ___________________________________Responsibilities:_______________________
_______________________________________________________________________
Dates of Employment: ____________________________________ Salary: ______________________
Reason for leaving: ___________________________________________________________________
Company/Organization: _______________________________________________________________
Address: _______________________________________ City: ____________________State: ______
Supervisor Name and Position: _____________________________Telephone #: _________________
Position Title: ___________________________________Responsibilities:_______________________
_______________________________________________________________________
Dates of Employment: ____________________________________ Salary: ______________________
Reason for leaving: ___________________________________________________________________
Personal References – Contact information for individuals you have known 2 years or more (excluding family)
Name: _________________________________________________ Telephone #: _________________
Relationship to applicant: __________________________________ Email: ______________________
How long have you known this person? _______________________
Name: _________________________________________________ Telephone #: _________________
Relationship to applicant: __________________________________ Email: ______________________
How long have you known this person? _______________________
Emergency Contact
Name: _________________________________________________ Telephone #: _________________
Relationship: _________________________
Statement of Understanding
I affirm that the information provided herein is true and accurate to the best of my knowledge.
I understand that my employment is contingent upon a successful background investigation.
I understand that I may be subject to termination should information come to light during the
background investigation that may conflict with my ability to perform my job responsibilities.
I further understand that any false statement on this application is sufficient reason for dismissal.
Signature: _______________________________________________ Date: ______________________
DO NOT WRITE BELOW THIS LINE
Date Received: _________________ By: ____________________ Date Reviewed: __________________By: ____________________
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