Updated Employment Application 7 2023

Southeast Tennessee Human EMPLOYMENT
Resource Agency
312 Resource Road/P.O. Box 909
Dunlap, TN 37327
APPLICATION
Office: 423-949-2191 – Fax: 423-949-4023 SETHRA is an equal opportunity employer
PERSONAL INFORMATION
Name (Last, First, Middle): Date:
Home Address:
City: State: Zip:
Contact Phone: E-mail Address:
Are you legally authorized to work in the United States? Circle one: Yes No
Please provide Visa No. and Expiration Date:
Have you ever worked for this company? Yes: No: When:
Do you have any friends or relatives working for SETHRA? Yes: No: Who:
Position Notice:
Some positions may require a criminal background check. You may be required to provide information about your criminal
history in order to be considered for this position.
Position You Are Applying For:
Part-Time Full Time Salary Requirement:
Referred by: Date You Can Start:
EDUCATION RECORD
High School (Name, City, State):
Business or Technical School (Name, City, State):
Degree Earned:
Undergraduate College (Name, City, State):
Degree, Major:
Graduate School (Name, City, State):
Degree, Subject:
SETHRA EMPLOYMENT APPLICATION (01/29/2018) 1

WORK HISTORY
(PROVIDE WORK HISTORY CONTAINING A CONTINUOUS DESCRIPTION OF
ACTIVITIES OVER THE PAST FIVE (5) YEARS)
1-Employer Dates Employed :
Address: Phone:
City: State: Zip:
Title/Duties:
Manager's Name and Title:
Reason for Leaving:
2-Employer Dates Employed:
Address: Phone:
City: State: Zip:
Title/Duties:
Reason for Leaving:
Address: Phone:
City: State: Zip:
Title/Duties:
Reason for Leaving:
Address: Phone:
City: State: Zip:
Title/Duties:
Manager’s Name and Title:
Reason for Leaving:

LIST THREE INDIVIDUALS AS PERSONAL REFERENCES, ONE (1) OF WHOM YOU HAVE
KNOWN FOR AT LEAST FIVE (5) YEAR
1-Name:
Dates and Years:
Work Phone: Home Phone:
Address:
City: State: Zip:
Relationship to You:
2-Name: Dates and Years:
Address:
City: State: Zip:
3-Name: Dates and Years:
Address:
City: State: Zip:
PLEASE READ AND SIGN
“I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I
UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY
APPLICATION MAY BE REJECTED AND, IF I AM EMPLOYED, MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME.
IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE COMPANY’S RULES AND REGULATIONS, AND I
AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITH OR
WITHOUT NOTICE, AT ANY TIME, AT EITHER MY OR THE COMPANY’S OPTION. I ALSO UNDERSTAND AND AGREE THAT
THE TERMS AND CONDITION OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT
NOTICE, AT ANY TIME BY THE COMPANY. I UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN ITS
EXECUTIVE DIRECTOR, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC
PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.”
THIS APPLICATION FOR EMPLOYMENT SHALL BE CONSIDERED ACTIVE FOR A PERIOD OF TIME NOT TO EXCEED 365
DAYS. ANY APPLICANT WISHING TO BE CONSIDERED FOR EMPLOYMENT BEYOND THIS TIME PERIOD SHOULD INQUIRE
AS TO WHETHER OR NOT APPLICATIONS ARE BEING ACCEPTED AT THAT TIME.
Signature: Date:

SOUTHEAST TENNESSE HUMAN RESOURCE AGENCY
EEOC COMPLIANCE QUESTIONNAIRE
THE FOLLOWING INFORMATION IS REQUESTED FOR COMPLIANCE WITH FEDERAL LAWS
ASSURING EQUAL EMPLOYMENT OPPORTUNITY WITHOUT REGARD TO RACE, COLOR,
CREED, RELIGION, GENDER OR SEX, (INCLUDING SEXUAL PREFERENCE OR SEXUAL
ORIENTATION), NATIONAL ORIGIN, AGE, DISABILITY, GENETIC INFORMATION, MILITARY OR
VETERAN STATUS OR ANY OTHER LEGALLY-PROTECTED CATEGORY.
THE INFORMATION REQUESTED IS VOLUNTARY AND WILL REMAIN SEPARATE
FROM YOUR APPLICATION FOR EMPLOYMENT.
1. Application Date / /
2. Applicant Name (Last Name, First Name, and Middle Initial)
3. Applicant Address (Street Address, City, State and Zip Code)
(Enter number in box)

4. EEO Codes
1. White (Not Hispanic or Latino)
2. Black of African American (Not Hispanic or Latino)
3. Hispanic or Latino
4. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
5. Asian (Not Hispanic or Latino)
6. American Indian or Alaskan Native (Not Hispanic or Latino)
7. Two or More Races (Not Hispanic or Latino)
5. Male Female
Position Applying For:
_________________________________
6. Disabled _____ Veteran _____
7. Referral Source (Enter letter in box)
A – Walk in / Write in
E – Minority Referral Agency
B – Ad Response G – Private Employment Agency
C – State Employment Agency H -- Other
D – College Placement Office
8. For Employer Purposes Only: EEO Category

___ Officials & Administrators ___ Professionals
___ Technicians ___ Protective Service
___ Paraprofessional ___ Admin Support
___ Skilled Craft ___ Service Maintenance
Applicant’s Signature Date Completed
4
Applicant’s Printed Name
SETHRA EMPLOYMENT APPLICATION (04/18/2023)

Updated Employment Application 7 2023

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Updated Employment Application 7 2023

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Southeast Tennessee Human EMPLOYMENT

City: State: Zip:

Contact Phone: E-mail Address:

Please provide Visa No. and Expiration Date:

Position You Are Applying For:

Part-Time Full Time Salary Requirement:

Referred by: Date You Can Start:

Business or Technical School (Name, City, State):

Undergraduate College (Name, City, State):

Graduate School (Name, City, State):

SETHRA EMPLOYMENT APPLICATION (01/29/2018) 1

City: State: Zip:

Manager's Name and Title:

Reason for Leaving:

2-Employer Dates Employed:

City: State: Zip:

Manager's Name and Title:

Reason for Leaving:

3-Employer Dates Employed:

City: State: Zip:

Manager's Name and Title:

Reason for Leaving:

4-Employer Dates Employed:

City: State: Zip:

Manager’s Name and Title:

Reason for Leaving:

SETHRA EMPLOYMENT APPLICATION (01/29/2018) 2

Work Phone: Home Phone:

City: State: Zip:

2-Name: Dates and Years:

Work Phone: Home Phone:

City: State: Zip:

3-Name: Dates and Years:

Work Phone: Home Phone:

City: State: Zip:

PLEASE READ AND SIGN

SETHRA EMPLOYMENT APPLICATION (01/29/2018) 3

2. Applicant Name (Last Name, First Name, and Middle Initial)

3. Applicant Address (Street Address, City, State and Zip Code)

(Enter number in box)

7. Referral Source (Enter letter in box)

8. For Employer Purposes Only: EEO Category

Applicant’s Signature Date Completed

SETHRA EMPLOYMENT APPLICATION (04/18/2023)

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