APPLICATION FOR EMPLOYMENT
A n Equal Opportunity Employer
W e do not discriminat e on t he basis of race, color, religion, nat ional origin, sex, age, disabilit y, genet ic inf ormat ion or any ot her st atus prot ect ed by law or
regulation. It is our intention that all qualified applicants are given equal opportunity and that selection decisions be based on job-related factors.
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Answ er each quest ion f ully and accurat ely. No act ion can be t aken on t his applicat ion unt il you have answ ered all quest ions.
Use blank paper if you do not have enough room on t his applicat ion. PLEASE PRINT, except f or signat ure on back of
applicat ion. In reading and answ ering t he f ollow ing quest ions, be aw are t hat none of t he quest ions are int ended t o imply
illegal pref erences or discriminat ion based upon non-job-relat ed inf ormat ion.
E
N
E
R Job Applied f or
A Are you seeking: Full-t ime
L
Today’ s Dat e
Part -t ime
Last Name
Temporary
First Name
employment ?
When could you st art w ork?
Middle Name
Present St reet Address
Cit y
Telephone Number
St at e
Zip Code
Are you 1 8 years of age or older? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Yes
No
Yes
No
Yes
No
(If you are hired, you may be required t o submit proof of age.)
If hired, you w ill be required t o f urnish proof of your eligibilit y t o w ork in t he U.S.
Have you ever applied here bef ore?
Yes
No
If yes, w hen?
Were you ever employed here?
Yes
No
If yes, w hen?
Have you ever been convict ed of any law violat ion in t he last seven years?
Include any plea of “ guilt y” or “ no cont est .” (Exclude minor t raf f ic violat ions.) . . . . . . . . . . . . . . . . . . . . .
If yes, give det ails
(A convict ion w ill not necessarily disqualif y an applicant f or employment .)
If employed, do you expect t o be engaged in any addit ional business
or employment out side of our job? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If yes, give det ails
For Driving Jobs Only: Do you have a valid driver’ s license? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Driver’ s License Number
Class of License
St at e Licensed In
Have you had your driver’ s license suspended or revoked in t he last 3 years? . . . . . . . . . . . . . . .
Yes
No
If yes, give det ails:
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D
U
C
A
T
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N
LIST NAM E AND ADDRESS OF SCHOOLS
Number of
Years
Complet ed
Diploma/
Degree/
Cert if icat e
High School or GED:
College or Universit y:
Vocat ional or Technical:
What skills or addit ional t raining do you have t hat relat e t o t he job f or w hich you are applying?
What machines or equipment can you operat e t hat relat e t o t he job f or w hich you are applying?
Subject s
St udied
names of employers in consecut ive order w it h present or last employer list ed f irst . Account f or all periods of t ime
W List
including milit ary service and any periods of unemployment . If self -employed, give f irm name and supply business ref erences.
O
R
K
H
I
S
T
O
R
Y
Not e: A job of f er may be cont ingent upon accept able ref erences f rom current and f ormer employers.
NAME OF EMPLOYER
JOB TITLE AND DUTIES
ADDRESS
DATES OF EMPLOYMENT (MO/YR): FROM
CITY, STATE, ZIP CODE
SUPERVISOR(S)
PAY: START $
TELEPHONE
Reason For Leaving
JOB TITLE AND DUTIES
ADDRESS
DATES OF EMPLOYMENT (MO/YR): FROM
SUPERVISOR(S)
PAY: START $
TELEPHONE
Reason For Leaving
JOB TITLE AND DUTIES
ADDRESS
DATES OF EMPLOYMENT (MO/YR): FROM
SUPERVISOR(S)
PAY: START $
TELEPHONE
Reason For Leaving
JOB TITLE AND DUTIES
ADDRESS
DATES OF EMPLOYMENT (MO/YR): FROM
SUPERVISOR(S)
PAY: START $
TELEPHONE
TO
FINAL $
NAME OF EMPLOYER
CITY, STATE, ZIP CODE
TO
FINAL $
NAME OF EMPLOYER
CITY, STATE, ZIP CODE
R
FINAL $
NAME OF EMPLOYER
CITY, STATE, ZIP CODE
TO
TO
FINAL $
Reason For Leaving
Have you w orked or at t ended school under any ot her names? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
If yes, give names:
E
F Are you present ly employed?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
E
If yes, w hom do you suggest w e cont act ?
R
E Have you ever been f ired f rom a job or asked t o resign? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
N
If yes, please explain:
C Give t hree ref erences, not relat ives or f ormer employers.
E
Name
Address
Phone
S
No
No
No
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING
I cert if y t hat all inf ormat ion provided in t his employment applicat ion is t rue and complet e. I underst and t hat any f alse inf ormat ion or omission may disqualif y me f rom f
urt her considerat ion f or employment and may result in my dismissal if discovered at a lat er dat e. I aut horize t he invest igat ion of any or all st at ement s cont ained in t his
applicat ion. I also aut horize, w het her list ed or not , any person, school, current employer, past employers and organizat ions t o provide relevant inf ormat ion and
opinions t hat may be usef ul in making a hiring decision. I release such persons and organizat ions f rom any legal liabilit y in making such st at ement s. I underst and
I may be required t o successf ully pass a drug screening examinat ion. I hereby consent t o a pre- and/or post -employment drug screen as a condit ion of employment , if
required. I underst and t hat if I am ext ended an of f er of employment it may be condit ioned upon my successf ully passing a complet e pre-employment physical
examinat ion. I consent t o t he release of any or all medical inf ormat ion as may be deemed necessary t o judge my capabilit y t o do t he w ork f or w hich 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 ORGANIZA
TION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN W RITING,
SIGNED BY THE PRESIDENT AND THE EM PLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY
EMPLOYMENT MAY BE TERMINATED AT ANY TIME, W ITH OR W ITHOUT REASON AND W ITH OR W ITHOUT NOTICE.
I have read, underst and, and by my signat ure consent t o t hese st at ement s.
Signat ure:
Dat e:
This applicat ion f or employment w ill remain act ive f or a limit ed t ime. Ask t he organizat ion’ s represent at ive f or det ails.