Your Logo Here

Application for Employment
Company Name Here

Applicant Information

Last
Name: / First Name: / M.I. / Date:
Street Address: / Apartment/Unit #
City: / State: / Zip:
Phone: / Email:
Date Available: / Social Security Number: / Desired Salary: / $
Are you currently working? / Yes ☐ No ☐

Position information

What position are you applying for?
What type of work are you applying for? ☐ Regular Part-Time ☐ Regular Full-Time ☐ Seasonal
What days can you work? (Check all that apply) ☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday ☐ Friday ☐ Saturday ☐Sunday
Hours available for work: / ☐ Available any time / From: / To:
Have you ever worked for this company? / Yes ☐ No ☐ / If so, when? / From: / To:
Do you have friends, relatives or acquaintances working for the company? / Yes ☐ No ☐ / If so, who? / Name: / Relation:

Education

High School: / Address:
City: / State: / Did you graduate? / YES ☐ / NO ☐ / Degree:
College: / Address:
City / State: / Did you graduate? / YES ☐ / NO ☐ / Degree:
Vocational School: / Address:
City / State: / Did you graduate? / YES ☐ / NO ☐ / Degree:

Previous Employment

1. Company: / Phone:
Address:
Supervisor Name: / Supervisor Number:
Job Title: / Responsibilities:
From: / To: / Reason for Leaving:
(optional)
2. Company: / Phone:
Address:
Supervisor Name: / Supervisor Number:
Job Title: / Responsibilities:
From: / To: / Reason for Leaving:
(optional)
3. Company: / Phone:
Address:
Supervisor Name: / Supervisor Number:
Job Title: / Responsivities:
From: / To: / Reason for Leaving:
(optional)

MISC.

If hired, would you have reasonable transportation to/from work? / Yes ☐ No ☐
Are you 18 years of age or older / Yes ☐ No ☐
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? / Yes ☐ No ☐
If hired, would you be able present evidence of your U.S. citizenship or proof of your legal right to work in the United States? / Yes ☐ No ☐
If hired, are you willing to submit to a drug test and/or background check? / Yes ☐ No ☐

Military Service

Branch: / Years of Service:
Rank: / Skills:

Disclaimer and Signature

By signing below:
I understand and acknowledge that I may need to submit to and pass a drug test and/or a background check.
I authorize the verification of any or all information listed above including previous employment
I certify that my answers are true and complete to the best of my knowledge.
I understand and acknowledge that any false or misleading information in my application or interview, may result in my disqualification of consideration and/or release from employment if selected.
Signature: / Date:

[Company Name] provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, [Company Name] complies with all applicable state and local laws governing nondiscrimination in employment. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.