Application for Employment

Position(s) Applying For

Date of Application

Other Reason:

Pay Expected:

Last Name

First Name

Middle Initial

Address

Number

Street

City

State

Zip Code

Home Phone

Business Phone

Social Security Number

If you are under 18 years of age, can you provide required proof of your eligibility to work?

YesNo

Have you ever filed an application with us before?

YesNo

If yes, give date:

Have you ever been employed with us before?

YesNo

If yes, give date:

Are you currently employed?

YesNo

May we contact your current employer?

YesNo

Are you currently prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Proof of Citizenship or Immigration status will be required upon employment.

YesNo

On what date would you be available for work?

Are you available to work:

Full TimePart TimeSummerTemporary

Are you currently on "lay off" status and subject to recall?

YesNo

Can you travel if a job requires it?

YesNo

Can you work overtime if a job requires it?

YesNo

Have you been convicted of a felony within the last 7 years?
Conviction will not necessarily disqualify an applicant from employment.

YesNo

If Yes, please explain.

Education

High School

Name & Address

Years Completed

Diploma Earned?

YesNo

Undergraduate College

Name & Address

Course of Study

Years Completed

Diploma/Degree Earned?

YesNo

Graduate Professional

Name & Address

Course of Study

Years Completed

Diploma/Degree Earned?

YesNo

Other Education

Other (Please specify):

Describe any specialized training, apprenticeship, skills, and extra-curricular activities.

OTHER QUALIFICATIONS: Summarize special job-related skills and qualifications acquired from employment or other experiences. (Include courses in accounting, sales, finance, & management.)

Specialized Skills

If applicable, list the years of experience for each of the skills listed below.

Fax Machine

Personal Computer Skills

Calculator

Word Processing

Typewriter

Spreadsheet

Sales

Cash Handling

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer 1

Employer

Employed Start Date:

Employed End Date (If still employed, choose today's date)

Phone Number

Address

Street

City

State

Zip Code

Job Title

Supervisor

Starting Salary

Final Salary

Reason For Leaving

Work Performed

Employer 2

Employer

Employed Start Date:

Employed End Date

Phone Number

Address

Street

City

State

Zip Code

Job Title

Supervisor

Starting Salary

Final Salary

Reason For Leaving

Work Performed

Employer 3

Employer

Employed Start Date:

Employed End Date

Phone Number

Address

Street

City

State

Zip Code

Job Title

Supervisor

Starting Salary

Final Salary

Reason For Leaving

Work Performed

List professional, trade, business, or civic activities and offices held.
You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

State any additional information you feel may be helpful to us in considering your application.

NOTE TO APPLICANTS: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.
Are you capable of performing in a reasonable manner, with or without reasonable accommodation, the activities involved in the job or occupation for which you have applied? A description of the activities involved in such a job or occupation can be found here.

YesNo

References

1

Name

Phone Number

Address

2

Name

Phone Number

Address

3

Name

Phone Number

Address

Confirmation of Authenticity

I certify that answers give herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. If you decide to engage an investigative consumer reporting agency to report on my credit and personal history, I authorize you to do so. If a report is obtained you must provide, at my request, the name of the agency so I may obtain from them the nature and substance of the information contained in the report.

This application for employment shall be considered active for a period of time not to exceed 180 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.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information give in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the employer.

I accept these terms as listed above and use this box as my digital signature.

Today's Date

Background Check Approval

Applicant Name

Date

Social Security Number

Date of Birth

I hereby give permission to have my prospective employer conduct a background check on myself for purpose of consideration for employment by this company.

I understand that the results of the background check will be kept strictly confidential and used only for the consideration of employment.

I accept these terms as listed above and use this box as my digital signature.