Date of Application:
/ /

Position(s) Applied For:

Referral Source:

Name of Source (if applicable):   

First Name:
  Middle Initial:

Last Name:

Street Address:

City:

State:

Zip Code:

Phone:

Mobile Phone:

Email Address:

Have you ever been employed here before?

Yes: No:

If yes, give date: / /

Are you employed now?

Yes: No:

May we contact your present employer?

Yes: No:

May we contact you at work?

Yes: No:

If yes, work number and best time to call:

Work phone:  

Best time to call - AM/PM :  

Are you prevented from lawfully becoming employed in this country?

Yes: No:

If hired, you will be required to submit documents sufficient to establish employment authorization and identity in compliance with the Immigration Reform and Control Act of 1986. While you need not provide this proof of citizenship or immigration status at the time you are interviewed, please be prepared to assure us that you can do so immediately upon being hired.

On what date would you be available for work?

/ /

Expected salary:  

Are you available to work?

Full Time : Part Time: Temporary:

Seasonal (what days?):

Sun: Mon: Tues: Weds: Thurs: Fri: Sat:

Will you work overtime if required?

Yes: No:

List professional, trade, business or civic activities and offices held. (You may exclude those which indicate race, color, religion, sex, age, national origin, disability):

Education:

Please list education or specialized experience which relates to the position(s) for which you are applying. Exclude names or terms which indicate, for example, race, color, religion, sex, age, disability or national origin.

High School:

Diploma or Degree:

Years completed:   9 10 11 12
 

College/University:

Diploma or Degree:

Years completed:   1 2 3 4
 

Graduate/Professional:

Diploma or Degree:

Years completed:   1 2 3 4

Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities:

Name:

Location:

Length of Course:

Was Course Completed: Yes: No:

Subject:

General:

Honors received:

Special Skills acquired from employment or other experience:

Employment Experience:

Start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which indicate, for example, race, color, religion, sex, age, disability or national origin:

Employer Name:

Employer Phone:

Address:

Job Title:

Immediate Supervisor/Title:

 
Dates Employed:

From: / /  To: / /

 
Hourly Salary/Rate:

Starting:  Final:

 
Reason for leaving:

 
May we contact for reference?

Yes: No: Later:

 
Summarize the nature of the work performed:

References:

List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three schools or personal references who are not related to you.

Reference #1:

Name:

Phone:

Years Known:

Reference #2:

Name:

Phone:

Years Known:

Reference #3:

Name:

Phone:

Years Known:

Applicant's Statement:

I understand and agree that any misrepresentation by me in this application will be sufficient cause for rejection of this application and/or termination of employment if I am hereafter employed by the Company. Furthermore, if I am hired, I understand that I am free to resign at any time, and that the Company reserves the right to terminate my employment at any time, with or without cause, and without prior notice. I understand that no representative of the Company has authority to make any representations or assurances to the contrary. I acknowledge and agree that any changes in such employment relationship must be made in writing and signed by an authorized representative of the Company.

I understand that if you make an offer of employment to me it may be a conditional offer of employment and I may be required to submit to a pre-employment medical exam and to provide information in response to your medical inquiries, the results of which might disqualify me from employment. If requested, I agree to furnish such information and to submit to such examinations.

I understand that I may be requested to submit to a test to detect the current illegal use of drugs and, if the test results identify that I am a current illegal user of drugs, I will not be eligible for employment by the Company. I further understand that I have the right to refuse to submit to such tests or to consent to such tests of my own free will.

I authorize the Company to make a thorough investigation of my past employment, education and job-related activities. To the extent permitted by law, I release the Company from any liability which might result from making such investigation and I also release from any liability all persons and entities supplying such information.

I acknowledge that the Company is an equal opportunity employer and that the Company does not discriminate in employment. I understand that no question on this application is used for the purpose of limited or excluding the Company's consideration of me for employment on a basis prohibited by federal, state or local law, nor is it used by the Company for the purpose of attempting to obtain information prohibited by federal, state or local law.

I understand that the company will consider this application to contain current information for a period of only sixty (60) days. At the expiration of sixty (60) days, if I have not heard from the Company and if I still desire to be considered for employment, I understand that it will be necessary for me to complete a new application.

I, the applicant, have read and agree to the terms of the Applicant's Statement.

I Agree:

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