EMPLOYMENT / JOB APPLICATION

PERSONAL INFORMATION

FULL NAME: Raymond Cole SerbentasDATE: 3/1/2021

First Middle Last

ADDRESS: 86 Greatwood Drive

Street Address Apt/Suite

White GA 30184
City State Zip Code

E-MAIL: bozeserbentas@gmail.comPHONE: 678-848-7690

SOCIAL SECURITY NUMBER (SSN): 000-000-0000

DATE AVAILABLE: 4/1/2021 DESIRED PAY: 13.50$☐ HOUR ☐ SALARY

POSITION APPLIED FOR: Junior Technician

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: 2021

GRADUATE? ☐ YES ☐ NO DIPLOMA:N/A

COLLEGE: _____________________ CITY / STATE: _____________________

FROM: _____________________ TO: _____________________

GRADUATE? ☐ YES ☐ NO DEGREE: _____________________

OTHER: Bartow College and Career Acadamy CITY / STATE: Cartersville, GA

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FROM: 2019 TO: 2021

DEGREE/CERTIFICATION: N/A

OTHER: _____________________ CITY / STATE: _____________________

FROM: _____________________ TO: _____________________

DEGREE/CERTIFICATION: _____________________

PREVIOUS EMPLOYMENT

EMPLOYER 1: Publix Store #0554

Company / Individual

E-MAIL: N/A PHONE: 770-606-2360

ADDRESS: 300 Cherokee Pl

Street Address Apt/Suite

Cartersville GA
City State Zip Code

STARTING PAY: 9.15$ ☐ HOUR ☐ SALARY ENDING PAY: 10.40$ ☐ HOUR ☐ SALARY

JOB TITLE: Customer Service Associate RESPONSIBILITIES: Bagging Groceries,

Carrying out customers to their cars and listening to requests, general cleaning duties,
training new hires.

FROM: 5/1/2018 TO: 3/1/2021

REASON FOR LEAVING: Lack of advancement opportunities

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: Beth Dunlap RELATIONSHIP: Manager

First Last

COMPANY: Publix TITLE: Customer Service Manager

E-MAIL: N/A PHONE: 770-606-2360

FULL NAME: RELATIONSHIP:

First Last

COMPANY: ________________________________ TITLE: ______________

E-MAIL: __________________________________ PHONE: _____________________

FULL NAME: _______________________________ RELATIONSHIP: ______________

First Last

COMPANY: ________________________________ TITLE: ______________

E-MAIL: __________________________________ PHONE: _____________________

MILITARY SERVICE

ARE YOU A VETERAN? ☐ YES ☐ NO

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BRANCH: _____________________ RANK AT DISCHARGE: _____________________

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: Raymond Serbentas DATE 3/1/2021

PRINT NAME Raymond Serbentas

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