Employment Application
Applicant Information
Full Name:
Date:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
City
State
Phone:
Date
Available:
Email
Social Security No.:
Position Applied
for:
Are you authorized to work in the
U.S.?
Have you ever been fired, dismissed,
or terminated from any position for
performance or disciplinary reasons?
Have you ever been convicted of a
felony?
YES
NO
YES
NO
YES
NO
If yes,
explain:
If yes, explain:
Education
High School:
Address:
No. of years
completed
Did you YES
graduate?
College:
No. of years
NO
Diploma:
Address:
Did you YES
1
NO
Degree:
ZIP Code
completed
graduate?
Other:
Address:
No. of years
completed
Did you YES
graduate?
NO
Degree:
References
Please list three professional references.
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Previous Employment
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:$
Ending Salary:$
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a
reference?
YES
Company:
Phone:
Address:
Job Title:
NO
Supervisor:
Starting Salary:$
Responsibilities:
2
Ending Salary:$
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a
reference?
YES
NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:$
Ending Salary:$
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a
reference?
YES
NO
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to
employment, I understand that false or misleading information in my application or interview may
result in my release. I hereby certify that I have not knowingly withheld any information that might
adversely affect my chances for employment and that the answers given by me to the questions and
statements on this application are true and correct. I hereby authorize Sandstone Diagnostics, Inc. (SDI)
to verify all information on this application. I also authorize my former employers and educational
institutions to give SDI any information they may have regarding me. I further certify that I have
personally completed this application. I understand that any omission or misstatement of material fact
on this application or on any document used to secure employment shall be grounds for rejection of this
application or for immediate discharge if I am employed, regardless of the time elapsed before
discovery. I understand that nothing contained in the application, or conveyed during any interview is
intended to create an employment contract between me and SDI. I understand that if employed, and in
consideration of my employment, I agree to conform to the rules and regulations of SDI. I also
understand that every aspect of my employment with SDI shall be on an at-will basis, meaning that I or
SDI may terminate my employment at any time, for any reason, with or without cause. I further
understand that SDI expressly reserves its inherent authority to manage and control the organization
and to exercise its sole discretion to determine all issues pertaining to my employment, including all
matters pertaining to promotion, job assignment, demotion, transfer and discipline.
Signature:
Date:
3