Application
Social Security Number:

Name:
(Last)
(First)

(Middle)

Home Phone No.
( )
Address:
(No. & Street)
(Apt #)
(City)
(State)
(Zip)

Business Phone No.
( ) Ext

18 Years or Over?
Yes No

Shift Desired:
Day Afternoons
Nights 12 Hour
Schedule:
Full Time
Part Time
Position Desired or Area of Interest:
1.


2.

Person to Notify in case of Emergency:

Home Phone No.
( )
Address:
Business Phone No.
( ) Ext

Are you eligible for employment in the United States? Yes No Alien No. (If Any)

Do you have a current state professional license/certification without restrictions? Yes No
(only answer if applicable to position for which you are applying)

If No, please explain

What starting salary range do you consider appropriate? $ to $ Per Hour Day Week

Have you previously applied at this company? Yes No /  If so, date and position

Have you ever been employed by this company? Yes No /  If so, date and position

Have you ever been known by or used any other name? Yes No

If yes, explain

Who referred you to this company? Agency Advertising Employee Other

Do you have any relatives already employed by this company? Yes No

If Yes, please list name and relationship


EDUCATION

School Name & Location
Course of Study
Did you Graduate?
No. of Years Completed
Degree Obtained
High School
Yes No
College
Yes No
Trade School
Yes No
Other
Yes No

Please indicate any professional, trade, office, technical, or other skills and abilities possessed by you (I.E. Typing, Shorthand, Office Machines, Dictaphone, Programming, Laboratory, CRT/Personal Computer).

SKILL
LENGTH & KIND OF TRAINING
YEARS OF EXPERIENCE

LIST OF PREVIOUS EMPLOYERS - MOST RECENT FIRST!

NOTE: Please give accurate, complete information on all full or part time positions held.

DATES:
MO-YR:
EMPLOYER: RESPONSIBILITES:

From:
To:    
Final Salary:
Supervisor's Name:
Reason for Leaving:

Name:
Address:
Phone: ( )
Type of Business:

Title of Position:
Duties (include Supervisions)

May we contact your present Employer?
Yes No

DATES:
MO-YR:
EMPLOYER: RESPONSIBILITES:

From:
To:    
Final Salary:
Supervisor's Name:
Reason for Leaving:

Name:
Address:
Phone: ( )
Type of Business:

Title of Position:
Duties (include Supervisions)

DATES:
MO-YR:
EMPLOYER: RESPONSIBILITES:

From:
To:    
Final Salary:
Supervisor's Name:
Reason for Leaving:

Name:
Address:
Phone: ( )
Type of Business:

Title of Position:
Duties (include Supervisions)

REFERENCES Give below the names of three persons not related to you, whom you have known at least one year and of whom we may make inquires.
NAME
ADDRESS
PHONE
BUSINESS
YEARS KNOWN

I have been provided with a job description for the position for which I am applying. Yes No
After considering this job description, do you have the ability to perform this job for which you have applied?
If not, please explain.


NOTICE OF MEDICAL EXAMINATION

Any offer of employment may be contingent upon your ability to pass a medical examination prior to the commencement of employment.


MILITARY

If you have served, indicated period from to
Branch Highest Rank or Rating
Reserve Status


CONVICTION RECORD

Have you ever been convicted of a crime? Yes No
If Yes, explain when, where and the nature of all criminal convictions
Are there any felony charges pending against you now? Yes No
If Yes, describe:
Company policy does not render conviction of a crime an absolute bar to employment. Such facts as the seriousness and nature of the offense or violation, how many years ago the offense occurred and rehabilitation will be considered by the Company in relation to the specific job which you seek.

 

APPLICANT'S CERTIFICATION AND AGREEMENT
(Please read carefully)

1. Certification of Truthfulness. I certify that all statements on this Application for Employment are true to the best of my knowledge. I understand and agree that the statements made herein may be investigated and if found to be false will be sufficient reason for not being employed, or if employed, will be cause for dismissal when discovered.
2. References. I authorize the references I have listed above, and any prior or current employer of mine, to give you any and all information concerning my previous employment, including any disciplinary information, and any pertinent information they may have, personal or otherwise, and in exchange for my consideration of employment, I release all parties from all liability for any damage that may result for furnishing information to you. Also, I hereby waive written notice to me that employment information is being provided by any person or organization.

3. Employment At-Will. If hired, in consideration of my employment, I agree to abide by the rules, policies and procedures of the Company. I further agree that my employment with the Company is at-will and can be terminated for any reason, with or without cause, and with or without notice at any time, at the option of either the Company or myself. I Understand that the Company may, from time to time, make unilateral changes in its rules, regulations and personnel practices and policies which will affect me and that my employment may be subject to unilateral adjustments in compensation, fringe benefits and other terms and conditions of employment, including layoffs. I also understand that no agent or representative of the Company has any authority to many any agreement contrary to the foregoing, except by a written employment contract signed by me and the Present of the Company or designate.

I agree to these terms Yes No               Sign on printed copy ______________________________