EMPLOYMENT / JOB APPLICATION

PERSONAL INFORMATION

FULL NAME: Skylar Hope Nachamkin DATE: 28 September 2020

First Middle Last

ADDRESS: 111 Aztec Way SE

Street Address Apt/Suite

Acworth GA 30102
City State Zip Code

E-MAIL:_skylarnachamkin23@gmail.com PHONE: 6785314588

SOCIAL SECURITY NUMBER (SSN): _____-____-_____

DATE AVAILABLE: 28 September 2020 DESIRED PAY: $25 ☐ HOUR ☐ SALARY

POSITION APPLIED FOR: Registered Nurse

EMPLOYMENT DESIRED: ☐ FULL-TIME ☐ PART-TIME ☐ SEASONAL

EMPLOYMENT ELIGIBILITY

ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S? ☐ YES ☐ NO*

HAVE YOU EVER WORKED FOR THIS EMPLOYER? ☐ YES* ☐ NO

*IF YES, WRITE THE START AND END DATES: ____________________________________

HAVE YOU EVER BEEN CONVICTED OF A FELONY? ☐ YES* ☐ NO

*IF YES, PLEASE EXPLAIN: ____________________________________________________

EDUCATION

HIGH SCHOOL: Woodland CITY / STATE: Cartersville, GA

FROM: 2017 TO: 2021

GRADUATE? ☐ YES ☐ NO DIPLOMA: _____________________

COLLEGE: Georgia Highlands CITY / STATE: Cartersville,GA

FROM: 2021 TO: 2025

GRADUATE? ☐ YES ☐ NO DEGREE: Bachelors of Nursing

OTHER: _____________________ CITY / STATE: _____________________

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FROM: _____________________ TO: _____________________

DEGREE/CERTIFICATION: _____________________

OTHER: _____________________ CITY / STATE: _____________________

FROM: _____________________ TO: _____________________

DEGREE/CERTIFICATION: _____________________

PREVIOUS EMPLOYMENT

EMPLOYER 1: Precision Tune Auto Care

_________________________________________________________
Company / Individual

E-MAIL: ________________________ PHONE: 7709538953

ADDRESS: 1775 Cobb Parkway se A

Street Address Apt/Suite

_Marietta GA 30060
City State Zip Code

STARTING PAY: $8 ☐ HOUR ☐ SALARY ENDING PAY $ 8 ☐ HOUR ☐ SALARY

JOB TITLE: Oil Bay Tech RESPONSIBILITIES: Change oil and keep bay clean

FROM: 2018 TO: 2021

REASON FOR LEAVING: I Started college

EMPLOYER 2: Waffle House
Company / Individual

E-MAIL: __________________________________ PHONE: (678) 574-6997

ADDRESS: 1133 GA-92,
Street Address Apt/Suite

Acworth GA 30102
City State Zip Code

STARTING PAY: $7.25☐ HOUR ☐ SALARY ENDING PAY: $7.25☐ HOUR ☐ SALARY

JOB TITLE: Door Corp RESPONSIBILITIES: greet everyone and keep restaurant clean

FROM: 2018 TO: 2020

REASON FOR LEAVING: I was sexually harassed by a customer

EMPLOYER 3: __________________________________________________________
Company / Individual

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E-MAIL: __________________________________ PHONE: _____________________

ADDRESS: ____________________________________________________________
Street Address Apt/Suite

____________________________________________________________
City State Zip Code

STARTING PAY: $_________ ☐ HOUR ☐ SALARY ENDING PAY: $_________ ☐ HOUR ☐ SALARY

JOB TITLE: ______________ RESPONSIBILITIES: _____________________________

FROM: _____________________ TO: _____________________

REASON FOR LEAVING: _______________________________________________________

REFERENCES
(PROFESSIONAL ONLY)

FULL NAME: Tony Dutra RELATIONSHIP: 1st Boss

First Last

COMPANY: Precision Tune Auto Care TITLE: owner

E-MAIL: __________________________________ PHONE: _____________________

FULL NAME: Keith Nation RELATIONSHIP: 2nd Boss

First Last

COMPANY: Waffle House TITLE: District Manager

E-MAIL: __________________________________ PHONE: _____________________

FULL NAME: _______________________________ RELATIONSHIP: ______________

First Last

COMPANY: ________________________________ TITLE: ______________

E-MAIL: __________________________________ PHONE: _____________________

MILITARY SERVICE

ARE YOU A VETERAN? ☐ YES ☐ NO

BRANCH: _____________________ RANK AT DISCHARGE: _____________________

FROM: _____________________ TO: _____________________

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TYPE OF DISCHARGE: _____________________

IF NOT HONORABLE, PLEASE EXPLAIN: ______________________________________

BACKGROUND CHECK CONSENT

IF ASKED, ARE YOU WILLING TO CONSENT TO A BACKGROUND CHECK? ☐ YES ☐ NO

DISCLAIMER

Applicant understands that this is an Equal Opportunity Employer and committed to excellence through
diversity. In order to ensure this application is acceptable, please print or type with the application being
fully completed in order for it to be considered.

Please complete each section EVEN IF you decide to attach a resume.

I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this
application leads to my eventual employment, I understand that any false or misleading information in my
application or interview may result in my employment being terminated.

SIGNATURE Skylar Nachamkin DATE 28 September 2020

PRINT NAME: Skylar Nachamkin

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