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An Equal Opportunity Employer: |
We do not discriminate on the basis of race, color,
religion, national origin, sex, age, disability, or any other status protected
by law or regulation. It is our intention that all qualified applicants be given equal
opportunity and that selection decisions be based on job-related factors. |
Instructions: |
Answer each question fully and accurately. No action can be taken on this
application until you have answered all questions. In reading and answering the following questions, be
aware that none of the questions are intended to imply illegal preferences or
discrimination based upon non-job-related information. |
Job Applied for | |
Today's Date |
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What employment are you seeking? |
  Full-Time
Part-Time
Temp. |
When could you start |
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Desired Salary | hour |
Email | |
Last Name | |
First Name | |
Middle Name | |
Telephone Number | |
Present Street Address | |
City | |
State | |
Zip | |
Are you 18 years of age or older? |
Yes:
No: |
(If you are hired, you may be required to submit proof of age.) |
Social Security#(optional) | |
If hired, can you furnish proof you are eligible to work in the U.S.? |
Yes:
No: |
Have you ever applied here before? |
Yes:
No: |
If yes,when? |
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Were you ever employed here? |
Yes:
No: |
If yes,when? |
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Have you ever been convicted of any law violation (Include any plea of "guilty" or "no contest".
Exclude minor traffic violations) |
Yes:
No: |
If yes, give details |
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(A conviction will not necessarily disqualify an applicant for employment.) |
If employed, do you expect to be engaged in any additional business or employment outside
of our job? |
Yes:
No: |
If yes, please explain |
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Do you have a valid driver's license? |
Yes:
No: |
Driver's License Number |
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Class of License | |
State Licensed In | |
Have you had your driver's license suspended or revoked in the last three years? |
Yes:
No: |
If yes, give details |
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List Name and Address of Schools |
Number of years completed/ Diploma/Degree Certificate |
Subjects Studied |
High School or GED: |
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College or University: |
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Vocational or Technical: |
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What skills or additional training do you have that relate to the job for which you are applying? |
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What machines or equipment can you operate that relate to the job for which you are applying? |
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List names of employers in consecutive order with present or last employer listed first.
Account for all periods of time including military service and any periods of unemployment.
If self-employed, give firm name and supply business references. Note: A job offer may be
contingent upon acceptable references from current and former employers. |
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Name of Employer | |
Job Title and Duties | |
Address | |
City, State, Zip Code | |
Employed From - To (Month,Year) | |
Supervisor | |
Telephone | |
Your Final Pay | |
Your Starting Pay | |
Reason for Leaving |
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Name of Employer | |
Job Title and Duties | |
Address | |
City, State, Zip Code | |
Employed From - To (Month,Year) | |
Supervisor | |
Telephone | |
Your Final Pay | |
Your Starting Pay | |
Reason for Leaving |
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Name of Employer | |
Job Title and Duties | |
Address | |
City, State, Zip Code | |
Employed From - To (Month,Year) | |
Supervisor | |
Telephone | |
Your Final Pay | |
Your Starting Pay | |
Reason for Leaving |
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Name of Employer | |
Job Title and Duties | |
Address | |
City, State, Zip Code | |
Employed From - To (Month,Year) | |
Supervisor | |
Telephone | |
Your Final Pay | |
Your Starting Pay | |
Reason for Leaving |
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Have you worked or attended school under any other name? |
Yes:
No: |
If yes, give names: |
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Are you presently employed? |
Yes:
No: |
If yes, whom do you suggest we contact? |
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Have you ever been fired from a job or asked to resign? |
Yes:
No: |
If yes, please explain: |
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Give three references, not relatives or former employers. |
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Name | |
Phone | |
Address | |
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Name | |
Phone | |
Address | |
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Name | |
Phone | |
Address | |
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SUBMITTING |
I certify that all information provided in this employment application
is true and complete. I understand that any false information or omission may disqualify
me from further consideration for employment and may result in my dismissal if discovered
at a later date. |
I authorize the investigation of any or all statements contained in this
application. I also authorize, whether listed or not, any person, school, current employer,
past employers, and organizations to provide relevant information and opinions that may be
useful in making a hiring decision. I release such persons and organizations from any legal
liability in making such statements. |
I understand I may be required to successfully pass a drug screening
examination. I hereby consent to a pre- and/or post-employment drug screen as a condition
of employment, if required. |
I understand that if I am extended an offer of employment it may be
conditioned upon my successfully passing a complete pre-employment physical examination.
I consent to the release of any or all medical information as may be deemed necessary to
judge my capability to do the work for which I am applying. |
I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT,
OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR
GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZATION
HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH
AGREEMENT MUST BE IN WRITING, SIGNED BY THE PRESIDENT AND THE EMPLOYEE. IF EMPLOYED, I
UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE
TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE. |
I have read, understand, and by my signature consent to these statements |
Signature |
Date
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