Application for Employment

 August 27, 2008

Please fill out the information below. All fields marked as required must be filled in to complete form submission, unless otherwise noted.

Position(s) Applied for...required
Referral Source required






Applicant Information required
Name

First

Middle (optional)

Last
Address
 
← optional
 

City

State
← 5 digits only
Zip Code
Phone

Example: 321-555-1234
Email
Additional Information
If necessary, the best time to call you at home is...
← click clock to change time
May we contact you at work?
Work number and best time to call ← click clock to select time
Have you submitted an application here before?
Have you ever been employed here before?
Date Available for work:
← click calendar to choose date
Type of employment desired?
Full-Time
Part-Time
Temporary
Seasonal
Educational Co-Op
Are you able to meet the attendance requirements of the position?
Will you work overtime if required?
Have you ever been bonded?
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?
Answering "Yes" to these questions does not constitute 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.
Employment History
Please provide the following information of your past and current employers, assignments, or volunteer activities, starting with the most recent. Explain any gaps in employment in the comments box at the bottom of this section
 
Employer #1 Name Telephone
Address
 
Supervisor Name Title
 
Dates Employed From To
Job Title Start Finish
Hourly Rate/Salary Start Finish
 
Summarize the type of work performed and job responsibilities
Reason for leaving
May we contact for reference?
 
Employer #2 Name Telephone
Address
 
Supervisor Name Title
 
Dates Employed From To
Job Title Start Finish
Hourly Rate/Salary Start Finish
 
Summarize the type of work performed and job responsibilities
Reason for leaving
May we contact for reference?
 
Employer #3 Name Telephone
Address
 
Supervisor Name Title
 
Dates Employed From To
Job Title Start Finish
Hourly Rate/Salary Start Finish
 
Summarize the type of work performed and job responsibilities
Reason for leaving
May we contact for reference?
Comments (Including explanation of any gaps in employment)
Skills and Qualifications
Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.
Educational Background (if job related)
List last three schools attended, starting with the most recent. Please provide all requested information, including number of years completed, degree or diploma earned (if any), Grade Point Average or Class Rank, and Major field of study (if applicable).
 
School #1
School Name
Years completed GPA / Class Rank
Degree / Diploma
Major Minor
 
School #2
School Name
Years completed GPA / Class Rank
Degree / Diploma
Major Minor
 
School #3
School Name
Years completed GPA / Class Rank
Degree / Diploma
Major Minor
References
List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
 
Reference #1
Name
Phone Years known
 
Reference #2
Name
Phone Years known
 
Reference #3
Name
Phone Years known
Other
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.
List any additional information that you would like us to consider.
Applicant Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

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) cancel further consideration of this application, or (ii) immediately discharge me from the employers service, whenever it is discovered.

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 such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a 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 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 cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period 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 authority to work in the United State and that federal immigration laws require me to complete an I-9 Form in this regard.

Do not submit this application until you have read the above application statement
By checking this box, I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.required