N.M. Admin. Code § 9.4.7.13
New Mexico commission for the blind:
Business Enterprise Program Manager
PERA Building, Room 553
Santa Fe, NM 87503 (505) 827-4479
Notice to Applicants: Federal and State law requires that all applicants be considered without regard to race, color, gender, age, national origin, religion, physical/mental impairment or political affiliation. We believe in and fully support Equal Employment Opportunity and will fulfill our obligation to the fullest.
PERSONAL DATA
Name:__________________________________ SSN: ___-__-____
Address:_______________________ Home Number: ( )____-____
City:__________________________ Alternate #: ( )____-_____
State_____________ Zip________________
Are you a United States Citizen? Yes________ No_______
If a non-United States Citizen, do you have a legal right to accept permanent employment in the United States? Yes______ No______
Alien Registration #___________________________
In case of emergency, notify (name)_______________________
Phone #:______________________Relationship__________________
Optional: Male_____ Female______ Date of Birth:____________
Marital Status: Single:_____ Married_____ Divorced_____Widowed______
Number of Dependents:_______
Do you have any physical impairments? Yes____ No_____ If yes, describe:
_________________________________________________________
_________________________________________________________
Have you ever been convicted of a crime? Yes_____ No_____ If yes, describe:
_____________________________________________________________
_____________________________________________________________
Do you have food service experience? Yes_____ No_____ If yes, what and where:
EDUCATIONAL BACKGROUND
High school graduate/GED certificate? Yes_____ No______
If not graduate, highest grade completed:______________
Have you attended a vocational/technical school? Yes____ No____
Name and location:_________________________________________
Major or field:___________________________________________
Graduated/completed? Yes____ No____ If no, # of hours completed________
Have you attended a business school? Yes____ No____
Name and location:_________________________________________
Major or field:______________________________________
Graduated/completed? Yes____ No____ If no, # of hours completed________
Have you attended a college or university? Yes____ No____
Name and location:________________________________________
Major or field:___________________________________________
Graduated/completed? Yes____ No____ If no, # of hours completed________
Other (non-listed) institution? Yes____ No____
Name and location:__________________________________________
Major or field:_____________________________________________
Graduated/completed? Yes____ No____ If no, # of hours completed________
WORK HISTORY
List all prior work experience, beginning with your most recent employment. If you do not have enough space, use a separate sheet for continuation. If you include a resume instead of completing the work history section, make sure that all of the requested information is included in the resume.
May we contact your current and previous employers for more information about your work history?
Yes_____ No______
Current or most recent employer:____________________________________
Mailing address:_________________________________________________
Type of business:_______________Telephone # () _____-_____________
Your job title:___________________________________________________
Length of time employed: Years _________ Pay rate: hourly, weekly, monthly
Months_________ Amount:_________
Dates employed: From:____________ To:___________________
Your job duties (please be specific):
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Reason for leaving:_______________________________________________
PREVIOUS EMPLOYER: _______________________________________
Mailing address:_________________________________________________
Type of business:________________Telephone # () ____-______________
Your job title:___________________________________________________
Length of time employed: Years _________ Pay rate: hourly, weekly, monthly
Months_________ Amount:_________
Dates employed: From:_____________ To:___________________
Your job duties (please be specific):
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Reason for leaving:______________________________________________
PREVIOUS EMPLOYER: ______________________________________
Mailing address:________________________________________________
Type of business:_______________Telephone # () ____-_______________
Your job title:__________________________________________________
Length of time employed: Years__________ Pay rate: hourly, weekly, monthly
Months_________ Amount:_______
Dates employed: From:___________ To:_______________________
Your job duties (please be specific):
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Reason for leaving:_______________________________________________.
PERSONAL ACHIEVEMENTS AND AWARDS
List any important personal achievements, recognitions or accolades you have earned.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
PERSONAL REFERENCES (not related)
Name Address Telephone
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Before you sign this application for employment, please check your answers to make sure that all questions have been completed properly and legibly. If you do not have enough space on this application, please use a separate sheet and make sure that the information includes that which is asked for on this application, and that your name appears on every sheet.
I, the below signed individual, hereby declare that, to the best of my knowledge and ability, the information on this application is true and factual. I understand that I will be required to provide proof of eligibility to work in the United States pursuant to the Immigration Reform and Control Act of 1986 as a condition of my employment.
I understand that false, misleading or incomplete statements could lead to rejection for consideration or possible dismissal.
Signature:____________________________ Date:______________________
N.M. Admin. Code § 9.4.7.13