Application for Employment

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Last Name *
First Name *
Middle Name *
Address *
City *
State *
Zip Code *
Telephone # *
Cellular/Other Phone #
E-mail Address *
Position(s) applied for *

Referral Source

(please check the appropriate category and list the source.)
Walk-in
Employee
Advertisement
Company's Website
Other Internet
School
Job Fair
Staffing Agency
Government Employment Agency
Other
If necessary, best time to call you is
Home    Cellular/Other
May we contact you at work? Yes    No
If yes,
work number best time to call
If you are under 18 and it is required, can you furnish a work permit? Yes    No
If no, please explain:
Have you submitted an application here before? Yes    No
If yes, give
Date(s) Position(s)
Have you ever been employed here before? Yes    No
If yes, give dates:
Form To
Is this application a request for reemployment following an extended military leave of absence from this company?
Yes    No
If yes, additional information may be requested.
Are you legally eligible for employment in this country? Yes    No
Date available for work
What is your desired salary range or hourly rate of pay?
$ Per
Type of employment desired: Full-Time    Part-Time    Educational Co-Op    Seasonal    Temporary
Will you relocate if job requires it? Yes    No
Will you travel if job requires it? Yes    No
If they have been explained to you, are you able to meet the attendance requirements of the position? N/A Yes No
Will you work overtime if required? Yes    No
If no, please explain:
Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)?
This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.
Yes    No    Need more information about the job's "essential functions" to respond
Driver's license number State
Have you ever been bonded? Yes    No
Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account
Have you ever pleaded "guilty" or "no contest" to or been convicted of a crime? Yes    No
If yes, please provide date(s) and details:
Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?
Yes    No
If yes, please explain:

Employment History

Starting with your most recent employer, provide the following information.
Employer Telephone #
Street address City State
Starting job title/final job title
Immediate supervisor and title (for most recent position held)
Why did you leave?
may we contact for reference? Yes    No    Later Email
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?
Dates employed:
To
Compensation (Starting)
Hourly    Salary    Per
Commission/Bonus/Other Compensation $
Compensation (Final)
Hourly    Salary    $ Per
Commission/Bonus/Other Compensation $
Employer Telephone #
Street address City State
Starting job title/final job title
Immediate supervisor and title (for most recent position held)
Why did you leave?
may we contact for reference?
Yes    No    Later
Email
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?
Dates employed:
To
Compensation (Starting)
Hourly    Salary    Per
Commission/Bonus/Other Compensation
Compensation (Final)
Hourly Salary Per $
Commission/Bonus/Other Compensation
Employer Telephone #
Street address City State
Starting job title/final job title
Immediate supervisor and title (for most recent position held)
Why did you leave?
may we contact for reference?
Yes No Later Email
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?
Dates employed:
To
Compensation (Starting)
Hourly Salary $ Per
Commission/Bonus/Other Compensation
Compensation (Final)
Hourly Salary $ Per
Commission/Bonus/Other Compensation
Employer Telephone #
Street address City State
Starting job title/final job title
Immediate supervisor and title (for most recent position held)
Why did you leave?
may we contact for reference?
Yes No Later Email
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?
Dates employed:
To
Compensation (Starting)
Hourly Salary $ Per
Commission/Bonus/Other Compensation
Compensation (Final)
Hourly Salary $ Per
Commission/Bonus/Other Compensation
Explain any gaps in your employment, other than those due to personal illness, injury or disability
If not addressed on previous page, have you ever been fired or asked to resign from a job? Yes No
If yes, please explain:

Skills and qualifications

Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying:
Computer Skills (Check appropriate boxes. Include software titles and years of experience.)
Word Processing Years: Spreadsheet Years:
Presentation Years: E-mail Years:
Internet Years: Other Years:
Other Years: Other Years:

Educational Background

Starting with your most recent school attended, provide the following information.
School (include City and State) years Completed Completed GPA Class Rank Major/Minor
Diploma GED
Degree Certification Other
Diploma GED
Degree Certification Other
Diploma GED
Degree Certification Other

References

List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
Name Title Relationship to you Telephone E-mail # of years Known

Social Security Number

# We will use this information only for employment purposes and make reasonable efforts to safeguard your privacy.

Related Information

To what job-related organizations (professional, trade, etc.) do you belong?
Exclude memberships that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve, National guard or any other similarly protected status.
Organization Offices Held
List special accomplishments, publications, awards, etc.
Exclude information that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve, National guard or any other similarly protected status.
In your current or a previous job, have you ever written instructions or directions to be followed by employees or customers?
Yes No Not Applicable
If yes, please explain
Is there any other job-related information you want us to know about you?

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resumé or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, genetic information, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature of Applicant Date

Typing your full name shall be construed as your electronic signature giving the employer the right to access to background checks, references, and other information referenced above.

This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts or services. The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any damages arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have.
Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.