Employment Application
The following information is requested so that we may make the best possible placement of employees within the firm. All portions of this application pertaining to you must be completed. We appreciate the time you spend completing the application. The firm, in accordance with state and Federal laws, does not discriminate on the basis of age, race, religion, color, gender, national origin, ancestry, disability, or any other protected class.

Applicant Information

Last Name / First / M.I. / Date
Street Address / Apartment/Unit #
City / State / ZIP
Phone / E-mail Address
Date Available / Social Security No. / Desired Salary
Position Applied for
Are you a citizen of the United States? / YES / NO / If no, are you authorized to work in the U.S.? / YES / NO
Have you ever worked for this company? / YES / NO / If so, when?
Have you ever been convicted of a felony? / YES / NO / If yes, explain

Education

High School / Address
From / To / Did you graduate? / YES / NO / Degree
College / Address
From / To / Did you graduate? / YES / NO / Degree
Other / Address
From / To / Did you graduate? / YES / NO / Degree

References

Please list three professional references. (Not a family member)
Full Name / Years Acquainted
Company / Phone
Address
Full Name / Years Acquainted
Company / Phone
Address
Full Name / Years Acquainted
Company / Phone
Address

Previous Employment (List Below your last 3 employers, starting with the last one first)

Company / Phone
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO

Military Service

Branch / From / To
Rank at Discharge / Type of Discharge
If other than honorable, explain

Disclaimer and Signature

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize CoxHollidaYoung PLLC to investigate, confirm, and supplement any information contained on this application, to contact former employers unless otherwise stated, and to perform background checks including investigation of criminal conviction records. I further release all parties from all liability for any damage that may result from furnishing the same to you.
I understand and agree that, if hired, my status will be that of an employee at will, with no contractual right, express or implied, to remain employed. In consideration of my employment, I specifically agree that my employment may be terminated, with or without cause or notice, at any time, at the option of either the employer or myself. I understand that no one, other than the Firm’s Managing Partner, in writing, may enter into my agreement for employment on my behalf or make any agreement contrary to the foregoing.
Signature / Date