Application for Employment
Name
Address
City
State
Zip
Telephone #
Mobile #
Email Address
Position(s) applying for:
Referral Source
(Please check the appropriate category and name the source)
Walk In
Employee
Company’s Website
Employment Agency
Staffing Agency
Advertisement
Other Internet
Other
If necessary, best time to call you at home is:
  
May we contact you at work?
If Yes, work number and best time to call:
  
If you are under 18 and it is required, can you furnish a work permit?
If no, please explain
Have you ever been employed here before?
If yes, give dates
From To
Are you legally eligible for employment in this country?
Date Available for work:
What is your desired salary range or hourly rate of pay?
$ Per
Type of employment desired:
Will you relocate/travel if the job requires it?
If they have been explained to you, are you able to meet the attendance requirements of the position?
Will you work overtime if required?
Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodations)?

This question is not designed to elicit information about an applicant’s disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.
Have you ever been bonded?
Have you been convicted of a felony, as an adult, within the last 5 years?

A conviction record will not necessarily be a bar to employment. Applicants are not obligated to disclose sealed or expunged records of convictions or arrests. It is the policy of the Company to perform background checks for criminal convictions
If yes, please explain:
Employment History
In the following spaces give a complete record of your last 10 years of employment including periods of unemployment, if any. Begin with your most recent employment and work back. If more space is needed, attach a supplementary sheet.
Employer #1  
Employer
Telephone
Address
City
State
Zip
Starting Position
Starting Salary
Last Position
Last Salary
Duties
Reason for Leaving
Other Positions Held
Immediate Supervisor
Employed
From To
 
If you were unemployed between these jobs, please indicated date of unemployment
From To
Employer #2  
Employer
Telephone
Address
City
State
Zip
Starting Position
Starting Salary
Last Position
Last Salary
Duties
Reason for Leaving
Other Positions Held
Immediate Supervisor
Employed
From To
 
If you were unemployed between these jobs, please indicated date of unemployment
From To
Employer #3  
Employer
Telephone
Address
City
State
Zip
Starting Position
Starting Salary
Last Position
Last Salary
Duties
Reason for Leaving
Other Positions Held
Immediate Supervisor
Employed
From To
   
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?
If yes, please explain.
Skills and Qualifications
Summarize any skills, licenses, accomplishments languages spoken and/or certificates that may assist you in performing the position for which you are applying.
Computer Skills

(Check the appropriate boxes. Include software titles and years of experience)
Word Processing Software Title Years:
Spreadsheet Software Title Years:
Presentation Software Title Years:
Email Software Title Years:
Internet Software Title Years:
Other Software Title Years:
Educational Background
Please provide the following information.
High School
School Name
City
State
Zip Code
Years Completed
Degree
College  
School Name
City
State
Zip Code
Years Completed
Degree
Major
Graduate School  
School Name
City
State
Zip Code
Years Completed
Degree
Major
Trade School  
School Name
City
State
Zip Code
Years Completed
Degree
Major
Other  
School Name
City
State
Zip Code
Years Completed
Degree
Major
Professional References
List the name and telephone number of three business/work references who are not related to you.
Reference #1
Name
Title
Relationship
Telephone
Years Known
Reference #2
Name
Title
Relationship
Telephone
Years Known
Reference #3
Name
Title
Relationship
Telephone
Years Known
Related Information
Do you have a commitment to a present or former employer that might affect or limit your right to be employed by us? (e.g. Restrictive Covenant, Non-Compete Agreement, Non-Disclosure, Confidentiality, Non-Solicitation obligation, etc.)
If yes, please explain:
I certify that all the 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, résumé, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, it’s 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 if 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.

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.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
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