Employment Application

Contact Information

Last Name

First Name

Middle Initial

Street Address

City/State

Zip Code

Home Phone Number

Cell Phone Number

Email Address

Job Information

Are you legally eligible for employment in the United States?

Position Desired

Wage/Salary Desired

Are you available to work Full Time?

Can you work overtime?

Have you ever worked for us before?

Yes No

If you have worked with us before, when? (month/year)

Date you can begin work?

Do you have a valid driver's license?

Yes No

Are you 18 years of age or older?

Yes No

Have you ever been convicted of a crime (other than a minor traffic violation), that has not been expunged by a court?

Yes No

If yes to the previous question, please describe in full

A conviction that has not been expunged will not necessarily disqualify you from employment with this company. However, if you fail to provide all requested information, your application will not be considered for further action. Also, failure to disclose your conviction history, as described above, will be considered falsification of the application and will be grounds for rejection of your application, or if hired, grounds for termination.

Education (High School)

Name of high school attended

City/State

Graduate?

GED?

Education (College)

Name of college or technical school

City/State

Graduate?

Diploma?

Skills

List any skills, training, or experience that you believe are relevant to the essential job functions of the position for which you are applying

Employment History

May we contact employers listed below?

Yes No

If you answered no to the previous question, please explain why

Have you ever been discharged from any employer or asked to resign?

Yes No

If you answered yes to the previous question, please explain why

Company #1

Company Name

Address

City/State/Zip Code

Job Title

Responsibilities

Dates of Employment (From/To)

Hourly Pay or Salary

Starting Pay

Ending Pay

Supervisor

Telephone

Reason for leaving

Company #2

Company Name

Address

City/State/Zip Code

Job Title

Responsibilities

Dates of Employment (From/To)

Hourly Pay or Salary

Starting Pay

Ending Pay

Supervisor

Telephone

Reason for leaving

Company #3

Company Name

Address

City/State/Zip Code

Job Title

Responsibilities

Dates of Employment (From/To)

Hourly Pay or Salary

Starting Pay

Ending Pay

Supervisor

Telephone

Reason for leaving

References (professional only)

Name

Occupation

Phone Number

Miscellaneous

What qualifications, abilities, and strengths do you have that will help you succeed in this position?

Carefully read each statement before clicking the submit button at the bottom

Any material misrepresentation or deliberate failure to respond to any inquiry on my application may be justification for refusal of-or, if employed, termination from employment

It is my understanding that the company may make a thorough investigation of the information I provide in my application for employment and may verify all dates given in my application for employment, related papers, or oral interviews. I authorize such investigation, and I release from liability any person giving or receiving any such information. I understand that falsification of data so given or other derogatory information discovered as a result of this investigation may prevent my being hired or, if hired, may subject me to immediate dismissal. I understand that if offered a position, a background check will be completed in compliance with the Fair Credit Reporting Act.

Although management makes every effort to accommodate individual preferences, business needs may at times make the following conditions mandatory: work schedule changes, overtime. I understand and accept these as a condition of my continuing employment with the company.

I further understand that this is an application for employment and that no offer of employment is being made at this time.

I further understand that, if I am employed, such employment will be as an employee at will and that my employment may be terminated at any time, with or without cause for notice, by me or by the company.

I have read, understand, and agree to the above statements.