Application For Employment

An Equal Opportunity Employer

We do not discriminate on the basis of race, color, religion, national origin, sex, age, or disability. It is our intention that all qualified applicants be given equal opportunity that selection decision be based on job related factors.

Answer each question fully and accurately – you may use not applicable (N/A) for questions that are not relevant. 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 or discrimination upon non-job related information.

Job Applied for

Today's Date

Are you seeking:
When could you start work?

Requested starting wage?

Last Name

First Name

Present Street Address

State

Middle Name

Telephone Number

City

Zip Code

Are you 18 years of age or older?
(If hired, you will be required to submit proof of age.)
Social Security

If hired, can you furnish proof you are eligible to work in the U.S?
Have you applied here before?
If yes, when?

Were you ever employed here?
If yes, when?

Have you ever been convicted of any law violation (except a minor traffic violation)?
If yes, give details

(A "Yes" answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying is also considered.)
Are you now or do you expect to be engaged in any other business or employment?
If yes, please explain

EDUCATION

List Name and Address of Schools

High School or GED
Number of years completed

Diploma/ Degree Certificate

College or University
Subjects Studied

Diploma/ Degree Certificate

Number of years completed

Vocational or Technical
Subjects Studied

Diploma/ Degree Certificate

Number of years completed

SPECIAL SKILLS

What skills or additional training do you have that are related to the job for which you are applying?

What machines or equipment can you operate that are related to the job for which you are applying?

How many days of work have you missed during the past year?
(Exclude absences due to disability or those covered by FMLA)

Do you have a valid driver's license?
Driver's License Number

Class of License

Have you had your driver's license suspended or revoked in the last 3 years?
If yes, give details

List professional, trade, business or civic activities and offices held.
(Exclude labor organizations and memberships which reveal, race, color, religion, national origin, sex, age, disability or other protected status)

WORK HISTORY

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military services and any periods of unemployment. If self-employed, give firm name and supply business reference.

PLEASE GIVE MONTH AND YEAR

Name of Employer

Address

City

State

Telephone

Title

Supervisor

Employed From

/

 

 

Employed To

/

Zip code

Pay Start $

Pay End $

Reason for living

Duties

Name of Employer

Address

City

State

Telephone

Title

Supervisor

Employed From

/

 

 

Employed To

/

Zip code

Pay Start $

Pay End $

Reason for living

Duties

Name of Employer

Address

City

State

Telephone

Title

Supervisor

Employed From

/

 

 

Employed To

/

Zip code

Pay Start $

Pay End $

Reason for living

Duties

REFERENCES

Have you worked or attended school under any other names?
If yes, give names

Are you presently employed?
If yes, whom do you suggest we contact

Have you ever been fired from a job or asked to resign?
If yes, explain

Give three references, not relatives or former employers
Name

Address

 

Phone

Name

Address

 

Phone

Name

Address

 

Phone

AFFIDAVIT

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

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 understand that the employer may request an investigative consumer report from a consumer reporting agency. This report many include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the discloser of the nature and scope of this investigation.

I authorize the investigation of any or all statements contained in this applications. I also authorize, where 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 that if am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examinations. I consent to the release of any or all medical information as may be deemed necessary to judge by capability to do the work for which I am applying.

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 THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GAURENTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND THAT MY EMPLOYEMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE.

I have read understand and by my signature consent to these statements.

Signature

Date

This application for employment will remain active for a limited time. Ask the organization representative for details.