Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. Use blank paper if you do not have enough room on this Application. PLEASE PRINT, except for signature. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non job-related information.
PLEASE PRINT
Position(s) Applied For:
Name:
Last / First / Middle
Address:
Street / City / State / ZIP Code
Telephone Number: / (______) / ______/ Social Security Number:
Area Code
Are you 18 years of age or older? (If you are hired you may be required to submit proof of age).
Are you legally eligible for employment in this country? / o Yes o No / Date available for work: / / / _
(Proof of U.S. citizenship or immigration status will be required upon employment.)
Have you filed an application here before? / o Yes o No / Salary at which you would start working: / $______
If yes, give date: / / / ____
Have you ever been employed here before? / o Yes o No / Type of employment desired:
If yes, give start/end dates - from: ______/______to: / ______/______/ o / Full Time
Will you work overtime if required? / o Yes o No / o / Part-Time
Will you travel if job requires it? / o Yes o No / o / Temporary
Do you have a valid driver’s license?
Driver’s License Number ______Class of License______State Licensed In_____
Have you had your driver’s license suspended or revoked in the last 3 years? If yes give details:______/ o Yes o No
o Yes o No / o / Seasonal
Have you been convicted of a felony in the last seven (7) years? / o Yes o No / o / Educational
(Such conviction may be relevant if job related, but does not bar you from employment.) / Co-op
If yes, please explain: ______
______/ An Equal Opportunity Employer
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, disability, or any other legally protected status. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.
EDUCATION AND TRAINING
A: List last three (3) schools attended, starting with last one. B: List number of years completed. C: Indicate degree of diploma earned, if any. D: Grade Point Average or Class Rank and E: Major field of study (if applicable).
A: School / B: No. Years Completed / C: Degree/Diploma / D: GPA/Class Rank / E: Major
What skills or additional training do you have that relate to the job for which you are______applying?______
OTHER (VOLUNTARY)
Vietnam Era Veteran: o Yes o No
If you wish to be identified as disabled according to the Rehabilitation Act of 1973, please indicate by checking the box: o Yes
AN EQUAL OPPORTUNITY EMPLOYER
EMPLOYMENT HISTORY (Move to voluntary section)Military Service: o Yes o No If yes, Branch of Service: ______Dates: _____/____ to _____/____
May we contact your past employer? o Yes o No May we contact your present employer? o Yes o No Whom should we contact?
PLEASE LIST THE PRESENT OR MOST RECENT JOB FIRST AND WORK BACK.
Employer: / Title of your position:
Address: / Describe duties and skills acquired:
From: Month/Year / To: Month/Year / Final Salary:
Name and Title of Supervisor: / Telephone: / Reason for Leaving:
Employer: / Title of your position:
Address: / Describe duties and skills acquired:
From: Month/Year / To: Month/Year / Final Salary:
Name and Title of Supervisor: / Telephone: / Reason for Leaving:
Employer: / Title of your position:
Address: / Describe duties and skills acquired:
From: Month/Year / To: Month/Year / Final Salary:
Name and Title of Supervisor: / Telephone: / Reason for Leaving:
Other/References
Have you worked or attended school under any other names? If yes, gives names: ______
Have you ever been fired from a job or asked to resign? If yes, please explain:______
Give three references, not relatives or former employers:
Name Address Phone
READ CAREFULLY BEFORE SIGNING
I certify that answers given herein are true and complete to the best of my knowledge. I understand that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed. Furthermore, I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that this application, verbal statements by management, or subsequent employment does not create an express or implied contract of employment nor guarantee employment for any definite period of time. I understand that no representative of the Employer has the authority to make any assurance to the contrary. Though salary may be expressed in hourly, monthly, or annual terms, the length of employment is at the will of either party.
I give the Employer the right to investigate any and all statements contained in this application. I also authorize the Employer to investigate all references and to secure additional information about me, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. I also authorize, whether listed or not, any person, school, current employee, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.
This application is current for 6 months. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary for me to fill out a new application.
I have fully read, understand, and by my signature, consent to these statements.
Signature of Applicant: ______Date: ______/______/______
fb.us.4615961.01