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Employment Application
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EQUAL OPPORTUNITY EMPLOYER
We are an equal opportunity employer. All applicants are considered for employment based upon their qualifications without regard to race, color, religion, sex, national origin, age, disability, citizenship or veteran status.
Date:
INTRODUCTORY INFORMATION
Name
Last, First, Middle
Social Security Number
Present Address
Telephone
Permanent Address
Telephone
Are you a U.S. Citizen or an alien authorized to work in the U.S.?
Yes
No
If less than 19 years of ago state your age:
EMPLOYMENT DESIRED
Position Desired:
Date you can work:
Salary desired:
Are you available to work?
Full-time
Part-time
On-call basis
Are you willing to travel?
Yes
No
Are you willing to relocate?
Yes
No
Are you willing to work any shift?
Yes
No
If no, during what hours are you available?
What days of the week are you available?
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Are you currently on lay-off or inactive status with any employer or other organization and subject to being recalled back to work or given a work assignment by that employer or organization?
Yes
No
If yes, state the approximate day you anticipate being recalled back to work or given a work assignment.
Have you ever applied to work for this company before?
Yes
No
If yes, state when, where and the position(s) you held and why you left.
Have you ever been employed by this company before?
Yes
No
If yes, who?
If yes, state when, where and the position(s) you held and why you left.
Do you know anyone who works here?
Yes
No
How were you referred to the company?
Have you ever been employed under a different name?
Yes
No
If so, state the name and whom you were employed by when you used it.
Are you currently subject to an agreement with any employer under which you have agreed not to work for a competitor of that employer or solicit clients of customers of that employer?
Yes
No
If yes, explain:
Have you ever been discharged or asked to resign by an employer?
Yes
No
If yes, explain:
Except for vacations, holidays and periods of disability, how many days were you absent from work in the last 12 months?
EDUCATION AND TRAINING
Please list the name and location of school attended, highest grade attended, if you graduated, degree(s) received, areas of study, and job-related courses/skills acquired below.
Name of Elementary and High School:
Highest grade attended?
Did you graduate?
Degree(s) received?
Areas of study:
Job-related courses/skills acquired:
College and Graduate School
Name of College/Graduate school:
Highest grade attended?
Did you graduate?
Degree(s) received?
Areas of study:
Job-related courses/skills acquired:
Trade or Technical School
Name of Trade or Technical School:
Highest grade attended?
Did you graduate?
Degree(s) received?
Areas of study:
Job-related courses/skills acquired:
Have you ever serviced in the United States Armed Forces?
Yes
No
If yes, state the branch in which you served and list any job-related skills you acquired or duties you performed:
MISCELLANEOUS INFORMATION
Please answer the questions below to the best of your ability.
Special Skills
To the extent you have not already done so earlier in this application, summarize any special skills or qualifications you have which relate to the position for which you are applying for:
Criminal Record
Have you ever been convicted of a crime, other than a minor traffic offense? Please answer Yes or No. If yes, please explain.
A RECORD OF A CRIMINAL CONVICTION DOES NOT NECESSARILY SERVE AS A BAR TO EMPLOYMENT.
Driver's License
Do you have a valid driver's license?
Yes
No
License number and State issued:
Has your driver's license ever been suspended or revoked?
Yes
No
If yes, please explain:
Driving Record
Have you ever been cited for any moving violations in the last 5 years?
Yes
No
If yes, please explain:
Have you had any accidents in the last 5 years?
Yes
No
If yes, please explain:
REFERENCES
Please provide the names of three persons, not related to you, whom you have known at least one year.
Name:
Address:
Business:
Name:
Years known:
Address:
Business:
Years known:
Name:
Years known:
Address:
Business:
EMPLOYMENT HISTORY
Please start with your present or last employer.
Current or most previous employer
Company name and address:
Nature of Business
Name and title of Supervisor:
Starting Position and Starting/Ending Salary:
Final Position and hours worked per week:
Date of Employment (from ___ to___)
Description of work and responsibilities:
Reason for leaving:
May we contact your employer?
Yes
No
Second most recent employment
Company name and address:
Nature of Business
Name and title of Supervisor:
Starting Position and Starting/Ending Salary:
Final Position and hours worked per week:
Date of Employment (from ___ to___)
Description of work and responsibilities:
Reason for leaving:
May we contact your employer?
Yes
No
Third most recent employment
Company name and address:
Nature of Business
Name and title of Supervisor:
Starting Position and Starting/Ending Salary:
Final Position and hours worked per week:
Date of Employment (from ___ to___)
Description of work and responsibilities:
Reason for leaving:
May we contact your employer?
Yes
No
Fourth most recent employment
Company name and address:
Nature of Business
Name and title of Supervisor:
Starting Position and Starting/Ending Salary:
Final Position and hours worked per week:
Date of Employment (from ___ to___)
Description of work and responsibilities:
Reason for leaving:
May we contact your employer?
Yes
No
PLEASE READ THE FOLLOWING PARAGRAPHS CAREFULLY AND SIGN
By signing this online form, this will count as your legal signature. Thank you!
I certify that all of the information I have supplied on this application is true, accurate and complete to the best of my knowledge and that I have not knowingly withheld any information which, if known to the Company, would affect my application unfavorably. I understand that any false, misleading and/or incomplete statements on this application, and/or in any interview, constitutes for, and will cause, the Company not to employ me, or if I am employed to terminate my employment. I authorize an investigation to be conducted concerning all of the information I have supplied on this application and all other information, which the Company deems to be relevant to my qualifications for employment. I further authorize my present employer, my former employers, any educational institution and any law enforcement organization, any consumer reporting agency, any professional or personal references, or any other appropriate source or individual to provide all information that is requested in connection with such investigation. I release the Company and all named and unnamed sources from any and all liability which may result from furnishing information concerning me. I agree to take any lawful examination or test, including any drug and/or alcohol test, required by the Company as a condition of my being hired, or if I am hired, as a condition of my continued employment. I further agree that my refusal to take any such lawful examination or test constitutes as grounds for, and will cause, the Company not to employ me, or if I am employed, to terminate my employment. I release the Company and all named and unnamed sources from any and all liability which may result from furnishing information concerning me. If I am employed, I agree that in consideration for my employment, I will conform to the rules and regulations of the Company. I understand that those rules and regulations may be altered, amended or repealed by the Company at any time, at the Company's sole option and without prior notice to employees. I acknowledge that if I am employed, my employment and compensation can be terminated at any times, with or without cause or notices, at the option of either the Company or myself. I understand that no representative of the Company has any authority to enter into any agreement for employment for any specified period of time, to assure any benefits or terms and conditions of employment, or to make any agreement contrary to the foregoing, except the President of the Company, who may only do so in writing. This employment application will be considered active for thirty (30) days from the date it is completed. After that period, a new application must be submitted for an applicant to be reconsidered for a position.
Name:
This counts as your legal signature of acceptance of the above.
Date:
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