Employment

An Equal Opportunity Employer
Company is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.

If you are human, leave this field blank.

Please print and fill out all sections

Applicant Name

Home Phone

Other

Email Address

Current Address

Number and street

City

State & Zip

How were you referred to Company?

Are you applying for:

Temporary work – such as summer or holiday work? :

Yes

No

Regular part-time work?

Yes

No

Regular full-time work?

Yes

No

If hired, on what date can you start working?

Can you work on the weekends?

Yes

No

Are you available to work overtime?

Yes

No

Salary desired

Personal Information:

Have you ever applied to / worked for Company before?

Yes

No

If yes, please explain (include date)

Do you have any friends, relatives, or acquaintances working for Company?

Yes

No

If yes, state name & relationship

If hired, would you have transportation to/from work?

Yes

No

Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age.)

Yes

No

If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?

Yes

No

If hired, are you willing to submit to and pass a controlled substance test?

Yes

No

Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation?

Yes

No

If no, describe the functions that cannot be performed

(Note: Company complies with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)

Education, Training and Experience

High School:

School name

School address

School city, state, zip

Number of years completed

Did you graduate?

Yes

No

Degree / diploma earned

College / University:

College name

College address

College city, state, zip

Number of years completed

Did you graduate?

Yes

No

Degree / diploma earned

Military

Degree / diploma earned

Branch

Rank in Military

Total Years of Service

Skills/duties

Related details

Do you speak, write or understand any foreign languages?

Yes

No

If yes, describe which languages(s) and how fluent of a speaker you consider yourself to be.

Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us?

Yes

No

If yes, please explain

Employment History

Are you currently employed?

Yes

No

If you are currently employed, may we contact your current employer?

Yes

No

Below, please describe past and present employment positions, dating back five years. Please account for all periods of unemployment. Even if you have attached a resume, this section must be completed.

Name of Employer

Name of Supervisor

Telephone Number

Business Type

Address

City, state, zip

Length of Employment (Include Dates)

Position & Duties

Reason for Leaving

May we contact this employer for references?

Yes

No

May we contact this employer for references?

Name of Employer

Name of Supervisor

Telephone Number

Business Type

Address

City, state, zip

Length of Employment (Include Dates)

Position & Duties

Reason for Leaving

May we contact this employer for references?

Yes

No

References

List below three persons who have knowledge of your work performance within the last four years. Please include professional references only.

Full Name

Telephone Number

Address

City, state, zip

Occupation

Number of Years Acquainted

REFERENCE2

Full Name

Telephone Number

Address

City, state, zip

Occupation

Number of Years Acquainted

REFERENCE3

Full Name

Telephone Number

Address

City, state, zip

Occupation

Number of Years Acquainted

Attach your Resume

Please Read and Initial Each Paragraph, then Sign Below

I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true & correct to the best of my knowledge and ability. I understand that any omission (i

I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or the company.

I permit the company to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experience

Applicant's Signature:

Date

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Employment

Please print and fill out all sections

Are you applying for:

Personal Information:

Education, Training and Experience

High School:

College / University:

Military

Employment History

References

REFERENCE2

REFERENCE3

Please Read and Initial Each Paragraph, then Sign Below

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