Application for Employment
Company provides equal employment opportunity to all qualified applicants without unlawful
regard to race, color, religion, sex, national origin, age, disability, or any other category
protected by applicable law.
Applicant Information
Date
Name
Last
First
Middle
Address
City
Number and Street
State
Zip Code
Contact Information
Home Phone
Work Phone
Other
Email
Employment Desired
Position applying for:
Site Leader Summer Food and Fun Program as
described in the attached job description
which, by reference, is incorporated herein
Date you can start
Salary
th
Part time
June 28 with prior training date
Are you presently employed?
If so, may we contact your employer?
Have you ever been employed with this company
before?
Is so, when?
Have you ever applied to this company before?
If so, when?
If you are hired, can you provide proof that you are authorized to work in the United States? Yes
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$10.00 an hour
No
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Employment History
This section must be completed entirely. Do not substitute a resume for this section. List all work
experience, paid or unpaid, beginning with your most recent job. Include all jobs, military service and
periods of unemployment lasting more than one month. Please indicate employers you would not wish to
be contacted. If more space is needed, additional pages can be added.
From
Employer
Starting Salary
To
Address
Phone No.
City
State
Position Title
Ending Salary
Zip
Supervisor
Full Time
Part Time
Position Responsibilities

Reason for leaving (not applicable to military service)
From
Employer
Starting Salary
To
Address
Phone No.
City
State
Position Title
Ending Salary
Zip
Supervisor
Full Time
Part Time
Position Responsibilities

Reason for leaving (not applicable to military service)
From
Employer
Starting Salary
To
Address
Phone No.
City
State
Position Title
Ending Salary
Zip
Supervisor
Full Time
Part Time
Position Responsibilities

Reason for leaving (not applicable to military service)
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Education
High School
Name and Location of School
Name:
College
City:
Name:
Circle
Last Year
Completed
Did you
graduate
Yes
Subjects studied and
degree(s) received
1234
State:
No
Yes
1234
City:
Graduate School
State:
No
Name:
Yes
1234
Other College or Graduate School
City:
Name:
State:
No
Yes
1234
City:
State:
No
Trade, Business, or Correspondence School
Yes
Name:
1234
No
City:
Please list any military training that is job – related:
State:
Please list any other skills, licenses or certificates that are job related:
PC skills include proficiency in:

Please list patents, publication and research projects (specify if assigned or owned):
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Please review and initial each statement, and sign your name below:
I acknowledge and agree that if hired, unless otherwise stated in writing and signed by the
president of the Company, I will be an "at will" employee, which means that the employment
relationship can be terminated at any time for any reason, with or without cause, by me or the
Company.
I understand that the Company requires preemployment drug testing for all applicants for
employment. Any applicant who has a positive drug test will not be hired. I hereby consent to a
urinalysis or other drug test and authorize the Company and any facility it designates to perform
any test on the specimen I provide. I further consent to the provision to and receipt by the
Company of all information regarding the drug test. I understand that any offer of employment is
conditional on my full cooperation with the drug testing process and on a negative test result. I
understand that if I refuse to sign this form, refuse to give a specimen when asked, attempt to
subvert the testing process in any way, or have a positive drug test, my application for
employment will be rejected. In return for being considered for employment, I consent to and
accept these conditions.
I authorize the Company to contact my education sources, former employers, and any other
persons who can verify any information in this application and to conduct any investigation it
considers necessary regarding my application for employment, including investigating all
statements made and information provided in this application and any attachments or supporting
documents. I also authorize the Company to request and receive all information it considers
necessary in investigating my application. I further authorize all contacted persons and entities to
provide information regarding this application and my background and suitability for
employment, and I release from all liability any and all persons or entities supplying such
information. I also release the Company from all liability related to requesting or receiving any
information and making any investigation regarding this application, my background, and my
suitability for employment.
I hereby acknowledge that I have read and understand each of the above statements. I certify
that all answers to questions and all other statements and information provided by me in this
application and all additional information I provided to the Company are true and complete to the
best of my knowledge. I understand that my giving any false or misleading information,
misrepresenting any facts, or making any misleading omissions will be grounds for denial of
employment, or discharge, if hired, regardless of when or how discovered.
Applicant’s Signature
Date
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