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Application for Employment
 
  Position applied for:
  Date of application:
  Referral Source: Advertisement Employee Relative Government Employment Agency
  Walk-In Private Employment Agency Other
    Name of source (if applicable):
  Name
(Last, First, Middle):
  Address: City: State: Zip:
  Telephone: Cell Phone:
  Social Security #:
  If necessary, best time to call you at home: Morning Afternoon Evening
  May we contact you at work? Yes No
  If Yes, work number and best time to call: AM/PM
  If you are under 18 and it is required, can you furnish a work permit? Yes No
  If no, please explain:
  Have you submitted an application here before? Yes NoIf Yes, give date:
  Have you ever been employed here before? Yes NoIf yes, give dates:
  Are you legally eligible for employment in this country? Yes No
  Type of employment desired: Date available to start:
  Will you relocate if job requires it: Yes NoWill you travel if job requires it: Yes No
  Are you able to meet the attendance requirements of the position? Yes No
  Will you work overtime if required? Yes NoIf No, please explain:
  Have you ever been bonded? Yes No
  Have been convicted of a crime in the last seven (7) years: Yes No
  If yes, please explain:
Conviction will NOT necessarily be a bar to employment, each instance and explanation will be considered
in relation to the position for which you are applying.
  Driver's license number if driving is an essential job function: State:
   
  EMPLOYMENT HISTORY
  Provide the following information for your past and current employers, assignments or volunteer activities, starting with the most recent. Explain any gaps in employment in the comments section below.
   
  Employer:
  Phone Number:
  Address:
  Job Title:
  Immediate Supervisor and Title:
  Reason for Leaving:
  May We Contact for References: Yes No Later
  Dates Employed: From: to (MM/DD/YY)
  Starting Hourly Rate/Salary: Final Hourly Rate/Salary:
  Summarize the type of work performed and job responsibilities:
 
  Employer:
  Phone Number:
  Address:
  Job Title:
  Immediate Supervisor and Title:
  Reason for Leaving:
  May We Contact for References: Yes No Later
  Dates Employed: From: to (MM/DD/YY)
  Starting Hourly Rate/Salary: Final Hourly Rate/Salary:
  Summarize the type of work performed and job responsibilities:
 
  Employer:
  Phone Number:
  Address:
  Job Title:
  Immediate Supervisor and Title:
  Reason for Leaving:
  May We Contact for References: Yes No Later
  Dates Employed: From: to (MM/DD/YY)
  Starting Hourly Rate/Salary: Final Hourly Rate/Salary:
  Summarize the type of work performed and job responsibilities:
 
   
  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)
 

A. List the last three (3) schools attended, starting with the most recent.
B. List number of years completed.
C. Indicate degree or diploma earned, if any.
D. Grade Point Average or Class Rank
E. Major Field of Study
F. Minor Field of Study (if applicable)

   
  School:
  Years Completed:
  Degree/Diploma
  GPA/Class Rank:
  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.
  Name:
  Telephone
  Years Known:
  Name:
  Telephone
  Years Known:
  Name:
  Telephone
  Years Known:
   
  ADDITIONAL INFORMATION
  List professional, trade, business, or civic associations and any offices held.
Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or any other similarly protected status.
  Organization:
  Offices Held:
  Organization:
  Offices Held:
  Organization:
  Offices Held:
   
  List Special Accomplishments, publications, awards, etc.
Exclude information which would reveal sex, race, religion, national origin, age, color, disability or any other similarly protected status.
 
   
  List any additional information you would like us to consider:
 
   
 

I understand that if I am employed, any misrepresentations or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer's service, whenever it is discovered.

I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information.

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 local,. state or federal law.

This application is current for only 60 days. 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 to 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 applicant ion does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer.

I understand it is this company's policy not to refuse to hire a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.

  Name: Date:
   
  AFFIRMATIVE ACTION VOLUNTARY INFORMATION
 

We consider all applicants for positions without regard to race, color, religion, sex, national origin, age, veteran/reserve/ national guard or any other similarly protected status.

To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application.

In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision.. The information used will be kept confidential in accordance with applicable laws and regulations.

  Position(s) applied for: Date: (MM/DD/YY)
  REFERRAL SOURCE
  Walk-in Government Employment Agency Private Employment Agency
  Employee Relative School
  Advertisement - Source: Other:
  Name of person who referred you (if applicable):
  APPLICANT INFORMATION
  Name: (Last, First, Middle)
  Telephone: Male Female
  Address: City: State: Zip:
  Please check one of the following Equal Employment Opportunity Identification Groups:
  White (not of Hispanic origin) Black (not of Hispanic origin) Hispanic
  American Indian/Alaskan Native Asian/Pacific Islander
   
 

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