Employment

Position applied for*

Date of application

Name*

First Middle Last

Address*

Street Address City State ZIP Code

Telephone #*

Cell #

Email address*

Have you been employed here before?

Yes
No

If yes, give dates*

Are you legally eligible for employment in this country?*

Yes
No

Desired Salary Range*

Date available for work*

Type of employment desired*

Full Time
Part Time
Temporary
Seasonal

Are you willing to work overtime?*

Yes
No

Education

School Name

Location - City / State

Course of Study / Major

# of Years

School Name

Location - City / State

Course of Study / Major

# of Years

Work Experience

Please list the names of your present and/or previous employers in chronological order with present or most recent employer listed first for the last 10 years. Attach additional sheets if needed. If self-employed, provide name and business references. You may include verifiable volunteer work, internships or military service.

Employer

Address

Phone

Employed From

Employed To

Job Title

Supervisor Name

May we contact?

Yes
No

Final Wage

Reason for leaving

Summarize the type of work performed and job responsibilities

Why did you leave?

Employer

Address

Phone

Employed From

Employed To

Job Title

Supervisor Name

May we contact?

Yes
No

Final Wage

Reason for leaving

Summarize the type of work performed and job responsibilities

Why did you leave?

Special Qualifications

List any special qualifications

References

Name / Title

Relationship to you

Phone

Years Known

Name / Title

Relationship to you

Phone

Years Known

Name / Title

Relationship to you

Phone

Years Known

Criminal History

Answering “yes” to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be considered.

Have you ever plead "guilty" or "no contest" to, or been convicted of a crime?*

Yes
No

If yes, please provide date(s) and details

Application Certification

THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT – EXPRESS OR IMPLIED – WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY. IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS A COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL.

I certify that all information I have provided 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 for all references, unless otherwise marked, 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, resume, or job interview. I hereby waive all rights and claims I may have regarding the employer its 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 authorize the company or its agents to confirm all statement contained in this application and/or resume as it relates to the position I am seeking to the extent permitted by federal, state or local law. I agree to authorize the company to complete a background investigation as permitted by federal, stand and/or local law.

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 from employment on any basis prohibited by applicable local, state or federal law.

I also understand if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States of America 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 (1) eliminate me from further consideration for employment, or (2) 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 Certification*

I agree

Education

Work Experience

Special Qualifications

References

Criminal History

Application Certification

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