Application for Employment

APPLICANT TO COMPLETE ALL INFORMATION REQUESTED. In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

Basic Info:

First Name: Middle Name: Last Name:

Present Address: City: State: Zip:

Previous Address: City: State: Zip:

Telephone #: Email Address:

Do you have a legal right to be employed in the United States? Yes (proof required) No

Are you over the age of 18? Yes No         Social Security #:

Company Experience

Have you worked for this company before? Yes No     Dates: From: To:

Where?:   Rate of Pay:   Position:

What was your reason for leaving:

General

Are you currently employed? Yes No    If not, when was your last day employed?

Position applying for:   Full Time Part Time Temporary Seasonal

Who referred you?:   Rate of pay expected:

Educational Background

Type of School Name and City Graduated? Course or Major
College Yes
Technical School Yes
High School Yes
Other Yes

Employment History

List all present and past employment, beginning with most recent.

1

Company Name:  Type of Business:

Address:  City:  State:  Zip:

Telephone #:  Name of Supervisor:

Dates Worked: From:  To:  Position(s) Held:  

Job Duties:  Reason for Leaving:

Base Gross Income Starting Wage Per Ending Wage Per Work Hours

2

Company Name: Type of Business:

Address: City: State: Zip:

Telephone #: Name of Supervisor:

Dates Worked: From: To: Position(s) Held:

Job Duties: Reason for Leaving:

Base Gross Income Starting Wage Per Ending Wage Per Work Hours

3

Company Name: Type of Business:

Address: City: State: Zip:

Telephone #: Name of Supervisor:

Dates Worked: From: To: Position(s) Held:

Job Duties: Reason for Leaving:

Base Gross Income Starting Wage Per Ending Wage Per Work Hours

4

Company Name: Type of Business:

Address: City: State: Zip:

Telephone #: Name of Supervisor:

Dates Worked: From: To: Position(s) Held:

Job Duties: Reason for Leaving:

Base Gross Income Starting Wage Per Ending Wage Per Work Hours

Work References

1

Name: Company:

Relationship and Title: Years Known:

Address: City: State:

Home Phone #: Work Phone #:


2

Name: Company:

Relationship and Title: Years Known:

Address: City: State:

Home Phone #: Work Phone #:


3

Name: Company:

Relationship and Title: Years Known:

Address: City: State:

Home Phone #: Work Phone #:


4

Name: Company:

Relationship and Title: Years Known:

Address: City: State:

Home Phone #: Work Phone #:

Special Skills

Please list any special skills or abilities you may have in the space below.

Applicant must Read and Agree to the following:

I certify that I have read and understand all of this employment application. It is agreed and understood that the employer or his agents may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons named herein from all liability for any damages on account of furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the results of a physical examination and drug test.

I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of the employer.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

I Agree that I have read and accept the statements above.