EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION

We are an equal employment opportunity employer. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability or any other status which may be protected by Federal, State or local law. Please complete the application in its entirety and be as accurate as possible.
Basic Information
Position(s) Applied for: *
Application Date: *

Month Day Year
Date
I am interested in: *

Full-time Part-time Seasonal Temporary Employment
If hired, I am available to start work on: *

Month Day Year
Date
Email Address *
Full Name *

First Name Middle Name Last Name
Phone Number *

Area Code Phone Number
Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

How did you hear about us? (choose one) *

	Online Source	Employee Name	Company Website	Job Fair Name	Staffing Agency	Other
Source (Name or Check)

If hired, can you provide proof that you are legally eligible to work in the United States? *

Yes No
Are you 18 years of age or older? (If no, proof of age may be required prior to starting work) *

Yes No
Have you applied with this company before? *

Yes No
If Yes, please indicate when:

Month Day Year
Date
Have you ever worked at this company?

Yes No
If Yes, please indicate when:

Month Day Year
Date
What rate of pay or salary do you expect to receive if hired? *
$/hr or salary
Have you ever been asked to resign or been fired from a job? *

Yes No
If Yes, explain:

Education and Applicable Skills

	Institution Name and Contact Information	Graduated: Yes or No	Diploma/Degree or Certificate	Subject or Major
High School or GED
Technical or Vocational
College or University
Other:

List any academic honors, professional, trade or business activities and offices held. (Do not list any which reflect your race, color, religion, gender, national origin, age, disabilities or veteran status.)
Describe any additional skills, training, certifications, licenses etc you may have that relate to the job you are applying for:

Employment Information
Include your employment information beginning with your current or most recent employer first. Do not exclude employment and be sure to account for all periods of time; including unemployment, self-employment, and military service.

Job offers may be contingent on acceptable references from current and previous employers.
Company Name *
Dates of Employment (month/year) *
(mm/yyyy) - (mm/yyyy)
Address, City, State, Zip Code *
Telephone Number *

Area Code Phone Number
Job Title and Duties *
Supervisor(s) Name *
Can we contact this person? *

Yes No
Supervisor(s) Number or Email
Reason for Leaving Employment *
Company Name
Dates of Employment (month/year)
(mm/yyyy) - (mm/yyyy)
Address, City, State, Zip Code
Wage/Salary
Starting $/hr and Final $/hr
Telephone Number

Area Code Phone Number
Job Title and Duties
Supervisor(s) Name
Can we contact this person?

Yes No
Supervisor(s) Number or Email
Reason for Leaving Employment
Company Name
Dates of Employment (month/year)
(mm/yyyy) - (mm/yyyy)
Address, City, State, Zip Code
Wage/Salary
Starting $/hr and Final $/hr
Telephone Number

Area Code Phone Number
Job Title and Duties
Supervisor(s) Name
Can we contact this person?

Yes No
Supervisor(s) Number or Email
Reason for Leaving Employment

Reference Information
Please provide three professional references who may be former employers or co-workers, who can provide professional reference information.

	Name	Contact Information	Relationship	Years Known
Reference #1
Reference #2
Reference #3

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING AND SUBMITTING
I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents)
is true and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts
may be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of
discovery.

I hereby consent and understand that I may be required to submit to a pre-employment medical examination, a pre – and/or
post-employment drug screen and background check as a condition of employment, if required. I understand that
unsatisfactory results, refusal to cooperate with, or any attempt to affect the results of these pre/post employment tests and
checks will result in withdrawal of any employment offer or termination of employment if already employed.

I hereby authorize any and all former employers, references, schools, courts and any others whether listed or not to provide
relevant information that may be useful in making a hiring decision. I release all parties involved from any and all legal liability
in providing such information.

I UNDERSTAND THAT SUBMISSION OF AN APPLICATION DOES NOT GUARANTEE EMPLOYMENT. I FURTHER UNDERSTAND THAT, THIS APPLICATION, VERBAL STATEMENTS MADE BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT, NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. I FURTHER UNDERSTAND THAT SHOULD AN OFFER OF EMPLOYMENT BE EXTENDED THAT EMPLOYMENT IS AT WILL, FOR NO SPECIFIED DURATION AND MAY BE
TERMINATED BY EITHER THE COMPANY OR MYSELF AT ANY TIME, WITH OR WITHOUT CAUSE OR NOTICE. I UNDERSTAND THAT NO REPRESENTATIVE OF COMPANY EXCEPT THE PRESIDENT HAS THE AUTHORITY TO
ENTER INTO ANY AGREEMENT GUARANTEEING ANY CONDITIONS OF EMPLOYMENT OR ANY AGREEMENT CONTRARY TO THE FOREGOING STATEMENTS AND THAT ANY SUCH AGREEMENTS MUST BE MADE IN WRITING
AND SIGNED BY THE PRESIDENT OF THE COMPANY.

By signing I acknowledge that I have read, understand and agree to these statements.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: