| GENERAL INFORMATION |
| Name:
SSN:
Email:
Date: |
| Driver's License No:
Driver's License State:
Phone Number: |
| Previous Last Name Used:
Current Address: |
| City: | State: | Zip: |
|
| If not a resident at current address for 2 years, give previous address and phone No. |
| Previous Address | | Previous Phone: |
| Lived there from: | | To: |
|
Citizenship (All persons, upon hiring, must verify citizenship status or provide valid authorization to work
in the U.S.) |
| Are you a U.S. Citizen?: YesNo | if not, are you authorized to work in the U.S?: YesNo |
|
| List the states and countries of residence for the past 7 (seven) years. |
|
|
| Have you ever been convicted of a felony? (Do not answer, "Yes" If your official conviction record has been annulled, expunged or sealed.
A past criminal record does not necessarily disqualify an applicant from employment.) YesNo |
| If yes, describe fully |
|
Do you have any relatives or friends working for the company?YesNo
If yes, give the name and department |
|
Have you ever worked for this company before?YesNo
If yes, when and in what department |
|
| In case of an emergency, whom should we notify? |
| Name:
Address:
Phone: |
|
| JOB INTEREST |
| Position applying for: | | Referred by: |
|
| Type of employment desired (check one)
Full Time
Part Time
Temporary
Summer |
|
| Shift preference: | | Salary required: |
|
| Are you willing to work overtime Yes
No | | Work weekends Yes
No
|
|
| Date available to begin work: |
| Are you 18 or over? Yes
No | | Are you 21 or over? Yes
No |
| If no, can you provide a work permit. Yes
No |
|
| EDUCATION |
|
| |
| REFERENCES |
| Please list two who know of your qualifications and work abilities (do not include relatives) |
| Name: | | Address: | | Phone: | | Occupation: |
|
| | | | | | | | |
|
| | | | | | | | |
|
| YOUR EMPLOYMENT HISTORY |
List below your employment history, beginning with your most recent employer. Account for all periods of time, including
part-time work, military service or unemployment. If you need more space use the Special Skills area.
May we contact your present employer for references?
Yes
No
|
| PREVIOUS EMPLOYER (MOST RECENT) |
| Name:
Address:
Phone: |
|
| Department: | | Supervisor: |
|
| Job Title and description of duties: |
|
| Reason for leaving:
|
|
| From (Mo/Yr):
To (Mo/Yr):
Salary Start:
End: |
| PREVIOUS EMPLOYER |
| Name:
Address:
Phone: |
|
| Department: | | Supervisor: |
|
| Job Title and description of duties: |
|
| Reason for leaving:
|
|
| From (Mo/Yr):
To (Mo/Yr):
Salary Start:
End: |
| PREVIOUS EMPLOYER |
| Name:
Address:
Phone: |
|
| Department: | | Supervisor: |
|
| Job Title and description of duties: |
|
| Reason for leaving:
|
|
| From (Mo/Yr):
To (Mo/Yr):
Salary Start:
End: |
| PREVIOUS EMPLOYER |
| Name:
Address:
Phone: |
|
| Department: | | Supervisor: |
|
| Job Title and description of duties: |
|
| Reason for leaving:
|
|
| From (Mo/Yr):
To (Mo/Yr):
Salary Start:
End: |
| SPECIAL SKILLS & QUALIFICATIONS |
|
RELEASE AND CONSENT | I understand and certify that all information supplied in this application is complete and correct.
Any false, misleading or incomplete information furnished by me regarding this application may result in the rejection of this
application or if employed dismissal. I understand that in consideration of my employment, I agree to conform to the rules and
regulations of the employer, and further agree that my employment and compensation are at the will of the employer and can be
terminated, with or without cause, and with or without notice, at any time at the option of either the employer or myself. I understand
and agree that these terms can only be modified in writing and signed by the President. No supervisor, representative, agent or other
employee of the Employer has now or has had in the past the authority to enter into any agreement for employment for a specified period
of time, or to make any agreement which is contrary to or in modification of the above terms, nor can any policies or practices of the
Employer either written or oral, modify the above terms.
I understand and agree to take any physical examination, including drug-screening test, all such tests will be administered in compliance
with the American With Disabilities Act.
I understand and hereby authorize all persons, schools companies, employers and/or their representatives to furnish verification so the
Employer its representatives or agents, any and all information set forth in this application and/or attached resume. In addition, I
hereby agree to hold harmless and to release from all liability all said person, schools, companies, employers and/or their representatives
from any and all claims that I may have, or which may arise, against any and/or all of them including the Employer, as a result of them
furnishing information to the Employer. I authorize the employer, should they employ me, to release employment references if my employment
becomes terminated for any reason. I also authorize the employer to conduct credit, police, criminal and driving record inquiries, or any
other employment related inquiries in compliance with the provisions of the Fair Credit Reporting Act 15 U.S.C. Section 168, ET. Seq. I
understand that the decision to hire my continued employment and me will be subject to the result of these inquiries.
I understand this application will be active for employment consideration for 30 days. After 30 days, if I wish to be considered for
employment, I must contact the Employer to determine if applications are being accepted.
I have read, understand and agree with this statement. |
| Applicant's Signature
Date |
|
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