Job Application

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Phone

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Application for Employment

We consider applications for all positions without regard to race, color, religion, creed, sex, national origin, disability, sexual orientation, citizenship status or any other legally protected status.

Position(s) Applied For

Date of Application

MM slash DD slash YYYY

How Did You Learn About Us?

Employment Agency

Relative

Friend

Inquiry

Other

Personal Information

Name(Required)

First Middle Last

Present Address

Street Address City State / Province / Region ZIP / Postal Code

Email(Required)

Telephone Number(s)

Best time to contact you at home is

Hours

Minutes

AM/PM

If you are under 18 years of age, can you provide required proof of your eligibility to work?

Yes

Have you ever filed an application with us before?

Yes

If Yes, give date

MM slash DD slash YYYY

Have you ever been employed with us before?

Yes

If Yes, give date

MM slash DD slash YYYY

Do any of your friends or relatives, other than spouse, work here?

Yes

Are you currently employed?

Yes

May we contact your present employer?

Yes

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

Yes

Proof of citizenship or immigration status will be required upon employment.

Date available for work

MM slash DD slash YYYY

What is your desired salary range?

Are you available to work?

Full-Time

Part-Time

Temporary

Please Indicate 1 2 3 Shift

Please Indicate Mornings, Afternoon or Evenings

Please Indicate Dates Available

Are you currently on "lay-off" status and subject to recall?

Yes

Can you travel if a job requires it?

Yes

Have you been convicted of a felony within the last five years?

Yes

A criminal record does not constitute an automatic bar to employment and will be considered only as relates to the job in question

We are an equal opportunity employer

Education

Elementary School

High School

Undergraduate College

Graduate Professional

Other (Specify)

Name and Address of School

Course of Study

Number of Years Completed

Diploma Degree

Name and Address of School

Course of Study

Number of Years Completed

Diploma Degree

Name and Address of School

Course of Study

Number of Years Completed

Diploma Degree

Name and Address of School

Course of Study

Number of Years Completed

Diploma Degree

Name and Address of School

Course of Study

Number of Years Completed

Diploma Degree

Describe any specialized training, apprenticeship, skills and extra curricular activities.

Describe any job-related training received in the United States military

Additional Information

Other Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.

Specialized Skills

Terminal

PC/Mac

Typewriter

WPM

Spreadsheet

Word Processing

Shorthand

WPM

Check Skills/Equipment Operated

Production/Mobile Machinery (list)

Other (list)

State any additional information you feel may be helpful to us in considering your application.

Note to applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING

Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accomodation

Yes

References

Reference 1 Name

Reference 1 Phone

Reference 1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reference 2 Name

Reference 2 Phone

Reference 2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reference 3 Name

Reference 3 Phone

Reference 3 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer 1

Address 1

Telephone Number 1

Job Title 1

Supervisor 1

Reason for Leaving 1

Dates Employed 1

From / To

Hourly Rate/Salary 1

Starting / Final

Work Performed 1

Employer 2

Address 2

Telephone Number 2

Job Title 2

Supervisor 2

Reason for Leaving 2

Dates Employed 2

From / To

Hourly Rate/Salary 2

Starting / Final

Work Performed 2

Employer 3

Address 3

Telephone Number 3

Job Title 3

Supervisor 3

Reason for Leaving 3

Dates Employed 3

From / To

Hourly Rate/Salary 3

Starting / Final

Work Performed 3

List professional, trade, business or civic activities and offices held.

You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status

Applicant's Statement

I certify that answers given herein are true and complete.

I authorize investigation of all statements contain in this application for as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unoless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the even of employment I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulation of the employer.

Signature of Applicant(Required)

Date

MM slash DD slash YYYY