PERSONAL INFORMATION

LAST NAME: _______________________________ FIRST NAME: ________________________________

PERSONAL ADDRESS: ___________________________________________________________________
PHONE: _____________________________________ CELLULAR: _______________________________
SOCIAL SECURITY NO: _____________________________MARITAL STATUS: _______________________
DATE OF BIRTH: DD_____MM_____YY________ AGE: _____ NATIONALITY: ______________________

DESIRED EMPLOYMENT

POSITION: __________________________________ SALARY DESIRED (weekly): ____________________

DATE YOU CAN START: ________________________ FULL TIME ______ PART TIME _______
ARE YOU WILLING TO DO OVERTIME? _________________________________________
DO YOU POSSESS A VALID DRIVERS LICENSE? _________________________________
LIST THE CLASS THAT YOU ARE ABLE TO DRIVE: ______________________________
LIST TYPE OF MACHINERY YOU CAN OPERATE: _______________, _________________, _____________
LIST KNOWLEDGE OF ANY COMPUTER PROGRAM YOU ARE FAMILIAR WITH: _______________________
_____________________________________________________________________________________
LIST LANGUAGES THAT YOU CAN SPEAK _______________, __________________, _________________
LIST LANGUAGES THAT YOU CAN WRITE ________________, _________________, _________________

EDUCATION

SCHOOLS ATTENDED DATES ATTENDED DEGREE

CONCENTRATION
Primary:
Secondary:
Trade School:
College:
University:

REFERECES (References cannot be of any family member)

NATURE OF
RELATIONSHIP WITH
NAME ADDRESS PHONE NO. REFERENCE
1.
2.
3.
4.
HEALTH
 HAVE YOU RECEIVED ANY COVID-19 VACCINATION? Yes ___ No ___
 DO YOU HAVE ANY UNDERLINEING HEALTH CONDITIONS? Yes ___ No ___
 DO YOU HAVE A CLEAN POLICE RECORD? ___ Yes ___No (If NO, please explain: _______________
_________________________________________________________________________________

LIST YOUR LAST THREE PLACE OF EMPLOYMENT. (Starting with most recent including
present)

NAME OF COMPANY ___________________________ NAME OF SUPERVISOR____________________

ADDRESS ___________________________________________ PHONE NO: _______________________
REASON FOR LEAVING/TERMINATION ______________________________________________________
TIME PERIODS OF EMPLOYMENT __________________________________________________________
WHAT WAS YOUR LAST JOB TITLE/POSITION? ________________________________________________

NAME OF COMPANY ___________________________ NAME OF SUPERVISOR____________________

ADDRESS ___________________________________________ PHONE NO: _______________________
REASON FOR LEAVING/TERMINATION ______________________________________________________
TIME PERIODS OF EMPLOYMENT __________________________________________________________
WHAT WAS YOUR LAST JOB TITLE/POSITION? ________________________________________________

NAME OF COMPANY ___________________________ NAME OF SUPERVISOR____________________

ADDRESS ___________________________________________ PHONE NO: _______________________
REASON FOR LEAVING/TERMINATION ______________________________________________________
TIME PERIODS OF EMPLOYMENT __________________________________________________________
WHAT WAS YOUR LAST JOB TITLE/POSITION? ________________________________________________

IN ABOUT 50 WORDS, DESCRIBE WHAT YOU BELIEVE TO BE THE NATIONAL INSTITUTE OF CULTURE AND
HISTORY ‘S (NICH) MISSION AND DESCRIBE HOW YOUR KNOWLEDGE AND SKILLS WOULD PLAY A ROLE
IN THE EFFICIENT AND EFFECTIVE ADVACNEMENT OF THE INSTITUITON:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Please include with this application (a) Resume (b) a current police record or a receipt (c) a copy of Social
Security Card (d) 2 Reference letter (previous employer/supervisor) (e) Driver’s License - if applicable (f)
Covid-19 Vaccination Card

I certify that the information that I have provided on this application is true and complete. I understand
that if any misrepresentation has been made by me verbally or in writing, any offer of employment made
to me may be withdrawn or my subsequent employment with the NICH may be terminated.

Applicant Signature: _________________________ Date:________________________