New Mexico Administrative Code › Title 9 - HUMAN RIGHTS › Chapter 4 - PERSONS WITH DISABILITIES › Part 7 - BUSINESS ENTERPRISE PROGRAM PROCEDURES MANUAL FOR BLIND VENDORS › Section 9.4.7.13 - APPENDIX 2: APPLICATION FOR BEP EMPLOYMENT

Current through Register Vol. 35, No. 13, July 16, 2024
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:
1.
				_________________________________________________________
2.
				_________________________________________________________
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:______________________