Application for Employment  

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Last Name:   First:
   Middle:
 Social Security Number:
  		   Date of application:
  		   Email address:
  		 
Home Address:
   City:
   State:
Zip Home Phone:   Mobile/Other Phone: Position(s) applied for:
 
         

If necessary, best time to call you at home is:
Will you travel if job requires it?   Yes No

If they have been explained to you,
are you able to meet the attendance
requirements of the position?
N/A   Yes   No
 
Will you work overtime if required?   Yes No

If no, please explain:

Driver's license number required if driving may be
required in the job for which you are applying:
  State:
 

Have you ever been bonded? Yes No

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 taken into account.

Have you ever pled "guilty" or "no contest" to,
or been convicted of a crime?   Yes No

If yes, please provide date(s) and details:
AM PM
 

May we contact you at work? Yes No

If yes, work number and best time to call:
     AM PM

If you are under 18 and it is required, can you
furnish a work permit? Yes No Over 18
If no, please explain:

Have you submitted an application here before?
Yes No      If yes, give date(s) and position(s):

Have you ever been employed here before?
Yes No           If yes, give date(s):
from     to   

Are you legally eligible for employment in this country?
Yes No   Date available for work:

What is your desired salary range or hourly rate of pay?
$    Per

Type of employment desired:
Full-Time   Part-Time   Temporary

Will you relocate if job requires it?   Yes No
 
 
 
Employment History    Starting with your most recent employer, provide the following information:
     
Employer: Telephone:  
Dates employed:  
From: To:
Compensation (Starting):
Hourly Salary    
$ per
Commision/Other  $
Compensation (Final):
Hourly Salary    
$ per
Commision/Other  $
       
 
Street Address: City: State:
Starting job title/final job title:  
Immediate supervisor and title (for most recent position):  
May we contact for reference?   Yes No Later

Why did you leave? 		 
Summarize the type of work performed and job responsibilities:
What did you like most about your position?  
What were the things you liked least about the position?  
   
 
     
Employer: Telephone:  
Dates employed:  
From: To:
Compensation (Starting):
Hourly Salary    
$ per
Commision/Other  $
Compensation (Final):
Hourly Salary    
$ per
Commision/Other  $
       
 
Street Address: City: State:
Starting job title/final job title:  
Immediate supervisor and title (for most recent position):  
May we contact for reference?   Yes No Later

Why did you leave? 		 
Summarize the type of work performed and job responsibilities:
What did you like most about your position?  
What were the things you liked least about the position?  
   
 
     
Employer: Telephone:  
Dates employed:  
From: To:
Compensation (Starting):
Hourly Salary    
$ per
Commision/Other  $
Compensation (Final):
Hourly Salary    
$ per
Commision/Other  $
       
 
Street Address: City: State:
Starting job title/final job title:  
Immediate supervisor and title (for most recent position):  
May we contact for reference?   Yes No Later

Why did you leave? 		 
Summarize the type of work performed and job responsibilities:
What did you like most about your position?  
What were the things you liked least about the position?  
 

Other Employment Information:		  

Explain any gaps in your employment, other than those due to personal illness, injury or disability: 		 
 
 
 
   
If not addressed above, have you ever been fired or asked to resign from a job?    Yes No
If yes, please explain: 		 
 
   
Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying:  
 
   
List special accomplishments, publications, awards, etc:
Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental, or physical disabilities, veteran/reserve national guard or any other similarly protected status.		  
 
   
In your current or a prior job, have you ever written instructions or directions to be followed by employees or customers?     Yes No N/A     If yes, please explain:  
 
   
Is there any other job-related information you want us to know about you?  
 
   
 

Educational Background :		      
Name of School:   Name of School:
Location of School:   Location of School:
Major/Minor:   Major/Minor:
Years completed:   Years completed:
GPA Class Rank:   GPA Class Rank:
List Diploma or Degree:   List Diploma or Degree:
         
         
Name of School:   Name of School:
Location of School:   Location of School:
Major/Minor:   Major/Minor:
Years completed:   Years completed:
GPA Class Rank:   GPA Class Rank:
List Diploma or Degree:   List Diploma or Degree:
 
  
  Referal source: Employee  Advertisement  Website  Other 
 

References:
List name and telephone number of three business/work references who are not related to you and are not
previous employers. If not applicable, list three school or personal references who are not related to you.
Name
Title
Relationship to You
Telephone
Number of Years Known
 
cover letter  
resume/CV  
   
Applicant Statement:  

I certify that all 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, resume or job interview. I hereby waive any and 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 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 prior notice, and the employer reserves the 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 perios 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 of 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.  
Yes  No