Vocational Rehabilitation Services
Employment Data Sheet-
Application and Résumé Builder
Demographic Information
Type the information below:
First name:
/ Middlename:
/ Lastname:
/ Date of birth:
Street address: / Apartmentnumber:
City: / State: / ZIPcode:
Mailing address, if differentfrom the address listed above.
Street address: / Apartment or P.O. box number:
City: / State: / ZIP code:
Phone 1: / Phone 2: / Phone 3:
Email: / Other contact method:
Types of driver’s licenses: Class C Commercial Restricted None
Languages spoken: English SpanishOther:
Describe reasons for gaps in either your work or volunteer history
Arrest And Conviction History
Have you ever been arrested or convicted of a criminal offense?NoYes
If yes, please give offense(s), date(s), location(s), and disposition of each case:
Offense/Charge
Date / Location / Disposition (payments, probation, registration):
Paid Work History
Record the information below for the four most recent paid positions you have held.
No work history to report
Employer: / Job title:
Start date: / End date: / Earnings: / Number of hours worked:
Address:
City: / State: / ZIPcode:
Supervisor’s name: / Phone:
Reason for leaving:
Do you think this employer will give you a goodreference? / Yes / No
Do you think that this employer would consider re-hiring you? / Yes / No
Roles: / Technical
Non-managerial / Supervisory or managerial
Number of employees supervised:
Type of employment: / Full-time
Part-time
Average hours worked / Temporary
or project / Summer / Contract
Other:
Job duties:
Employer: / Job title:
Start date: / End date: / Earnings: / Number of hours worked:
Address:
City: / State: / ZIP code:
Supervisor’s name: / Phone:
Reason for leaving:
Do you think this employer will give you a good reference? / Yes / No
Do you think that this employer would consider re-hiring you? / Yes / No
Roles: / Technical
Non-managerial / Supervisory or managerial
Number of employees supervised:
Type of employment: / Full-time
Part-time
Average hours worked / Temporary
or project / Summer / Contract
Other:
Job duties:
Employer: / Job title:
Start date: / End date: / Earnings: / Number of hours worked:
Address:
City: / State: / ZIP code:
Supervisor’s name: / Phone:
Reason for leaving:
Do you think this employer will give you a good reference? / Yes / No
Do you think that this employer would consider re-hiring you? / Yes / No
Roles: / Technical
Non-managerial / Supervisory or managerial
Number of employees supervised:
Type of employment: / Full-time
Part-time
Average hours worked / Temporary
or project / Summer / Contract
Other:
Job duties:
Employer: / Job title:
Start date: / End date: / Earnings: / Number of hours worked:
Address:
City: / State: / ZIP code:
Supervisor’s name: / Phone:
Reason for leaving:
Do you think this employer will give you a good reference? / Yes / No
Do you think that this employer would consider re-hiring you? / Yes / No
Roles: / Technical
Non-managerial / Supervisory or managerial
Number of employees supervised:
Type of employment: / Full-time
Part-time
Average hours worked / Temporary
or project / Summer / Contract
Other:
Job duties:
Employer: / Job title:
Start date: / End date: / Earnings: / Number of hours worked:
Address:
City: / State: / ZIP code:
Supervisor’s name: / Phone:
Reason for leaving:
Do you think this employer will give you a good reference? / Yes / No
Do you think that this employer would consider re-hiring you? / Yes / No
Roles: / Technical
Non-managerial / Supervisory or managerial
Number of employees supervised:
Type of employment: / Full-time
Part-time
Average hours worked / Temporary
or project / Summer / Contract
Other:
Job duties:
Volunteer History
Record the information below for the three most recent volunteer positions you have held.Include church activities, community service assignments, trustee positions, etc.
No volunteer history to report
Agency: / Volunteer title:
Start Date: / End date:
Address:
City: / State: / ZIPcode:
Supervisor’s name: / Phone:
Number of hours volunteered: / Reason for leaving:
May we contact this agency to gain information about your volunteer work? / Yes / No
Do you think this agency will give you a good reference? / Yes / No
Do you think this agency could and wouldconsider hiring you as an employee? / Yes / No
Volunteer duties:
Agency: / Volunteer title:
Start Date: / End date:
Address:
City: / State: / ZIP code:
Supervisor’s name: / Phone:
Number of hours volunteered: / Reason for leaving:
May we contact this agency to gain information about your volunteer work? / Yes / No
Do you think this agency will give you a good reference? / Yes / No
Do you think this agency could and wouldconsider hiring you as an employee? / Yes / No
Volunteer duties:
Agency: / Volunteer title:
Start Date: / End date:
Address:
City: / State: / ZIP code:
Supervisor’s name: / Phone:
Number of hours volunteered: / Reason for leaving:
May we contact this agency to gain information about your volunteer work? / Yes / No
Do you think this agency will give you a good reference? / Yes / No
Do you think this agency could and wouldconsider hiring you as an employee? / Yes / No
Volunteer duties:
Reference Details
Record the information below for each reference.
Name: / Relationship to reference and reference’s job title: / How long have you known the reference?
Company name:
Phone: / Email:
Address:
City: / State: / ZIP code:
Name: / Relationship to reference and reference’s job title: / How long have you known the reference?
Company name:
Phone: / Email:
Address:
City: / State: / ZIP code:
Name: / Relationship to reference and reference’s job title: / How long have you known the reference?
Company name:
Phone: / Email:
Address:
City: / State: / ZIP code:
Name: / Relationship to reference and reference’s job title: / How long have you known the reference?
Company name:
Phone: / Email:
Address:
City: / State: / ZIP code:
Career Objectives
Record career objective(s) below.
Training History Information
Record training details below.
No training history to report
Institution name:
Course title: / Total hours:
Course status: / Completed / Enrolled / Incomplete
Course description:
Institution name:
Course title: / Total hours:
Course status: / Completed / Enrolled / Incomplete
Course description:
Institution name:
Course title: / Total hours:
Course status: / Completed / Enrolled / Incomplete
Course description:
Institution name:
Course title: / Total hours:
Course status: / Completed / Enrolled / Incomplete
Course description:
Occupational License or Certification Information
Record training details below. Record N/A if a question does not apply.
No occupational license or certification information to report.
Type: Certification License Registration
Other (specify):
Issuer:
Title:
Number issued:
County: / City: / State:
Date issued: / Recertification date: / Expiration date:
High School and GED Information
Name of school district:
High school name: / Phone:
Address:
State: / ZIP code: / County:
Date started high school: / Date graduated: / Date of GED:
College Education History
Name of school:
City: / State:
Dates attended: / Program completed? Yes No
Major and minor areas of study:
Name of school:
City: / State:
Dates attended: / Program completed? Yes No
Major and minor areas of study:
Name of school:
City: / State:
Dates attended: / Program completed? Yes No
Major and minor areas of study:
Name of school:
City: / State:
Dates attended: / Program completed? Yes No
Major and minor areas of study:
DARS1890 (11/17) A+Employment Data Sheet Application and Résumé BuilderPage 1 of 2