Employment Application

For this type of employment, state law requires a criminal record check and drug screening as a condition of 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.
Name:*
First Last
Email:*
Applicant ID Number:
Address*
Street Address City State ZIP Code
Phone:*
Cellular/Other Phone:
Position(s) applied for:*
Date of application:*
MM slash DD slash YYYY
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
Walk-in Source:*
Employee Source:*
Advertisement Source:*
Company's Website Source:*
Other Internet Source:*
School Source:*
Job Fair Source:*
Staffing Agency Source:*
Government Employment Agency Source:*
If necessary, best time to call you is:*

: Hours

Minutes

AM/PM
Phone Number:*
- Home
- Cellular/Other
Home Phone:*
Cellular/Other Phone:*
May we contact you at work?*
- Yes
- No
Work Phone:*
Best time to call:*

: Hours

Minutes

AM/PM
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) and positions(s)*
Have you ever been employed here before?*
- Yes
- No
Employed from:*
MM slash DD slash YYYY
Employed to:*
MM slash DD slash YYYY
Is this application a request for reemployment following an extended military leave of absence from this company?*
If yes, additional information may be requested
- Yes
- No
Are you legally eligible for employment in this country?*
- Yes
- No
Date available for work:*
MM slash DD slash YYYY
What is your desired salary range or hourly rate of pay?*
Type of employment desired:*
- Educational Co-Op
- Full-Time
- Seasonal
- Part-Time
- Temporary
Will you relocate if the job requires it?*
- Yes
- No
Will you travel if the 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. Those 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:

Required if driving may be required in the job for which you are applying.
Driver's license state
Have you ever been bonded?
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.
- Yes
- No
Have you ever pleaded "guilty" or "no contest" to or been convicted of a crime?*
- Yes
- No
If yes, please provide dates and details:*
Have you entered into an agreement with any former employer or other party (such as a noncompetion 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.
First Employer Name:
Employment Start Date:
MM slash DD slash YYYY
Employment End Date:
MM slash DD slash YYYY
Compensation ( Starting )
- Hourly
- Salary
Hourly Rate:
Salary ( Monthly/Yearly ):
Commission/Bonus/Other Compensation:
Compensation ( Final )
- Hourly
- Salary
Hourly Rate:
Salary ( Monthly/Yearly ):
Commission/Bonus/Other Compensation:
Telephone:
Address:
Street Address City State
Starting job title:
Final job title:
Immediate supervisor and title (for most recent postion held):
May we contact for reference?
- Yes
- No
- Later
Supervisor Email:
Why did you leave?
Summarize the type of work performed and job responsibilities:
What did you like most about your position?
What did you like least about your position?
Second Employer Name:
Employment Start Date:
MM slash DD slash YYYY
Employment End Date:
MM slash DD slash YYYY
Second Job Compensation ( Starting )
- Hourly
- Salary
Hourly Rate:
Salary ( Monthly/Yearly ):
Commission/Bonus/Other Compensation:
Second Job Compensation ( Final )
- Hourly
- Salary
Hourly Rate:
Salary:
Commission/Bonus/Other Compensation:
Telephone:
Address:
Street Address City State
Starting job title:
Final job title:
Immediate supervisor and title (for most recent postion held):
May we contact for reference?
- Yes
- No
- Later
Supervisor Email:
Why did you leave?
Summarize the type of work performed and job responsibilities:
What did you like most about your position?
What did you like least about your position?
Third Employer Name:
Employment Start Date:
MM slash DD slash YYYY
Employment End Date:
MM slash DD slash YYYY
Third Job Compensation ( Starting )
- Hourly
- Salary
Hourly Rate:
Salary ( Monthly/Yearly ):
Commission/Bonus/Other Compensation:
Third Job Compensation ( Final )
- Hourly
- Salary
Hourly Rate:
Salary:
Commission/Bonus/Other Compensation:
Telephone:
Address:
Street Address City State
Starting job title:
Final job title:
Immediate supervisor and title (for most recent postion held):
May we contact for reference?
- Yes
- No
- Later
Supervisor Email:
Why did you leave?
Summarize the type of work performed and job responsibilities:
What did you like most about your position?
What did you like least about your position?
Fourth Employer Name:
Employment Start Date:
MM slash DD slash YYYY
Employment End Date:
MM slash DD slash YYYY
Fourth Job Compensation ( Starting )
- Hourly
- Salary
Hourly Rate:
Salary ( Monthly/Yearly ):
Commission/Bonus/Other Compensation:
Fourth Job Compensation ( Final )
- Hourly
- Salary
Hourly Rate:
Salary:
Commission/Bonus/Other Compensation:
Telephone:
Address:
Street Address City State
Starting job title:
Final job title:
Immediate supervisor and title (for most recent postion held):
May we contact for reference?
- Yes
- No
- Later
Supervisor Email:
Why did you leave?
Summarize the type of work performed and job responsibilities:
What did you like most about your position?
What did you like least about your position?
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
Computer Skills (Check appropriate boxes. Include software titles and years of experience.):*
- Word Processing
- Spreadsheet
- Presentation
- E-mail
- Internet
Word Processing programs and years of experience:
Spreadsheet programs and years of experience:
Presentation programs and years of experience:
Presentation programs and years of experience:
E-mail programs and years of experience:
Internet programs and years of experience:
Other programs and years of experience:
Educational Background
Starting with your most recent school attended, provide the following information.
First School (include City and State)
Years Completed:
First School Completed:
- Diploma
- GED
- Degree
- Certification
- Other
Degree:*
Certification:*
Other:*
GPA Class Rank:
Major/Minor:
Second School (include City and State)
Years Completed:
Second School Completed:
- Diploma
- GED
- Degree
- Certification
- Other
Degree:*
Certification:*
Other:*
GPA Class Rank:
Major/Minor:
Third School (include City and State)
Years Completed:
Third School Completed:
- Diploma
- GED
- Degree
- Certification
- Other
Degree:*
Certification:*
Other:*
GPA Class Rank:
Major/Minor:
Fourth School (include City and State)
Years Completed:
Fourth School Completed:
- Diploma
- GED
- Degree
- Certification
- Other
Degree:*
Certification:*
Other:*
GPA Class Rank:
Major/Minor:
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.
First Reference:
Name:*
Title:
Relationship to you:*
Telephone:
E-mail:
Number of years known:*
Second Reference:
Name:*
Title:
Relationship to you:*
Telephone:
E-mail:
Number of years known:*
Third Reference:
Name:*
Title:
Relationship to you:*
Telephone:
E-mail:
Number of years known:*
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.
First Organization:
First Organization Offices Held:
Second Organization:
Second Organization Offices Held:
Third Organization:
Third Organization Offices Held:
Fourth Organization:
Fourth Organization Offices Held:
List special accomplishments, publications, awards, etc.
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.
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, it's 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, resume or job interview, I hereby waive any and all right 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 agreement contrary to the foregoing express language are valid unless they are in writing and signed 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.

The Company does not tolerate unlawful discrimination in it’s 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. Example 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 picture 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 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

Employment History

Skills and Qualifications

Educational Background

References:

Related Information

Applicant Statement

Click here to make a donation