APPLICATION FOR WKU LEARN AND EARN PROGRAM:

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Our business partners are equal opportunity employers and recruit, advertise, employ, promote, transfer, discipline, and dischargewithout regard to race, color, creed, national origin, age, disability, sex, marital status, ancestry, medical condition, veteran status or sexual orientation.

PERSONAL

Last Name: Click here to enter text. First Name: Click here to enter text. Middle Initial: Click to Enter

Date of Birth: Click to Enter(FORMAT: month/day/year)WKU Student ID Number: Click here to enter text.

Are you legally authorized to work in the United States for any employer? ☐ Yes ☐ No

Street Address:Click to Enter

City: Click to Enter State:Click to EnterZip:Click to EnterMobile phone number:Click here to enter phone

Age (ONLY if under 18): Please enter your age. Email: Click here to enter text. Alternate Phone: Click here to enter phone

EMPLOYMENT

Desired Location(s) (choose all that apply): ☐Barren Co.☐Warren Co.☐Hart Co. ☐Hardin Co. ☐Other (specify):

Current class schedule:Click to Enter

Are you willing to work any shift? ☐ Yes ☐ No Date available for work:

EXPERIENCE: START WITH THE MOST RECENT POSITION . If you are currently employed, may we contact your employer? Yes ☐ No ☐

Company: Click to Enter
Address: Click here to enter text.
Employed from: Click to Enter.to:Click to Enter.
Name of Immediate Supervisor: Click to Enter / Position: Click to Enter.
Telephone:Area Code+ Phone
Reason for Leaving:Click to Enter.
Ending Salary: Enter Salary
Company: Click to Enter
Address: Click here to enter text.
Employed from: Click to Enter.to: Click to Enter.
Name of Immediate Supervisor: Click to Enter / Position: Click to Enter.
Telephone:Area Code+ Phone
Reason for Leaving:Click to Enter.
Ending Salary: Enter Salary
Company: Click to Enter
Address: Click here to enter text.
Employed from: Click to Enter.to: Click to Enter.
Name of Immediate Supervisor: Click to Enter / Position: Click to Enter.
Telephone:Area Code+ Phone
Reason for Leaving:Click to Enter.
Ending Salary: Enter Salary
Company: Click to Enter
Address: Click here to enter text.
Employed from: Click to Enter.to: Click to Enter.
Name of Immediate Supervisor: Click to Enter / Position: Click to Enter.
Telephone:Area Code+ Phone
Reason for Leaving:Click to Enter.
Ending Salary: Enter Salary

MILITARY

Date Entered: Click here to enter a date.Date Discharged: Click here to enter a date.

Rank: Click here to enter text.Branch of Service: Click here to enter text.

Reserve or National Guide Status: ☐ Non-Member ☐ Active ☐ Inactive

Special Training: Click here to enter text.If Active, Name of Unit: Click here to enter text.

EDUCATION

High School/GED / Name: Click to Enter
City/State: Click to Enter / Name on Diploma: Click to Enter
Diploma Received: Yes ☐ No ☐
Dates Attended: Click to Enter.to: Click to Enter.
College/University / Name: Click to Enter
City/State: Click to Enter / Major Field of Study: Click to Enter
Degree Received: Yes ☐ No ☐
Dates Attended: Click to Enter.to: Click to Enter.
Graduate School / Name: Click to Enter
City/State: Click to Enter / Major Field of Study: Click to Enter
Degree Received: Yes ☐ No ☐
Dates Attended: Click to Enter.to: Click to Enter.
Business/Trade School / Name: Click to Enter
City/State: Click to Enter / Major Field of Study: Click to Enter
Diploma Received: Yes ☐ No ☐
Dates Attended: Click to Enter.to: Click to Enter.

SPECIALIZED SKILLS: (list production or office machines you can operate)

Click to Enter

Please write a brief statement explaining why you would like to participate in Learn and Earn.

Click to Enter

APPLICANT – PLEASE READ CAREFULLY

I understand that submission of this application is no way implies that I will be employed.

I hereby represent that each answer to a question herein and all other information otherwise furnished is true and correct. I further represent that such answers and information constitute a full and complete disclosure of my knowledge with respect to the question. In the event that I am employed by a business partner, I agree to comply with all of its rule and regulations to include working overtime if assigned. I understand this application is not a contract. I understand I must be available to work any shift (day or evening) as a condition of employment. I hereby authorize my former employer and references to give any information regarding my employment with them, and in addition, to furnish any information they have concerning me. If employed, I agree to be photographed by Learn and Earn/business partner.

Further, I give Learn and Earn/business partner my permission to verify any or all of the information concerning my employment and education with the appropriateindividuals, institutions, organizations or government agencies, this may include driving history and workers compensation claim history. Ihereby release WKU/Learn and Earn/business partner from all claims and liability for any damages resulting from the information obtained.

In completing this application for employment I agree that if hired I have the right to resign and the business partner has the right to terminate myemployment at any time for any reason, with or without cause. This is the complete agreement between Learn and Earn/business partner and myself on this term of myemployment.

Signature of ApplicantDate

COMPLETE IN MS WORD, SAVE AND EMAIL COMPLETED APPLICATION TO: