Application for Employment

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, veteran status or any other legally protected status.

SECTION 1 of 4

Position(s) Applied for*:

How did you hear about us?

If Other, please explain:

If Referral, please list the name of the person who referred you:

Last Name*:
First Name*:

Email*

Address*:

City*:
State:
Zip:

Phone Number:

What is the best time to reach you? AMPM

If you are under 18 years of age, can you provide required proof of eligibility to work?
YesNo

Have you ever filed an application with us before?
YesNo
If yes, give date:

Have you ever been employed with us before?
YesNo
If yes, give date:

Do any of your friends or relatives, other than spouse, work here?
YesNo
If yes, state name, relationship and location:

Are you currently employed?
YesNo

May we contact your present employer?
YesNo

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
YesNo
Proof of citizenship or immigration status will be required upon employment.

Date available to work:

What is your desired salary range?

Are you available to work: Full timePart timeTemporary
Shifts: 123
If part time, shift preferred: MorningAfternoonEvening

Are you currently on "lay-off" status and subject to recall?
YesNo

Can you travel if a job requires it?
YesNo

SECTION 2 of 4

Education

High School:
Name and Address of School:
Number of Years Completed:
Diploma/Degree:

Undergraduate College:
Name and Address of School:
Course of Study:

Number of Years Completed:
Diploma/Degree:

Graduate/Professional:
Name and Address of School:
Course of Study:

Number of Years Completed:
Diploma/Degree:

Other (Specify):
Name and Address of School:
Course of Study:

Number of Years Completed:
Diploma/Degree:

Work Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer 1:

Dates Employed:

Hourly Rate/Salary: Start
End

Address:

Phone Number:

Starting/Present Job Title:

Supervisor:

Work Performed:

Reason for Leaving:

May we contact? YesNo

Employer 2:

Dates Employed:

Hourly Rate/Salary: Start
End

Address:

Phone Number:

Starting/Present Job Title:

Supervisor:

Work Performed:

Reason for Leaving:

May we contact? YesNo

Employer 3:

Dates Employed:

Hourly Rate/Salary: Start
End

Address:

Phone Number:

Starting/Present Job Title:

Supervisor:

Work Performed:

Reason for Leaving:

May we contact? YesNo

Employer 4:

Dates Employed:

Hourly Rate/Salary: Start
End

Address:

Phone Number:

Starting/Present Job Title:

Supervisor:

Work Performed:

Reason for Leaving:

May we contact? YesNo

Comments: Include explanation of any gaps in employment.

SECTION 3 of 4

Describe any specialized training, apprenticeship, skills and extra-curricular activities.

Describe any job-related training received in the United State military.

List professional, trade, business or civic activities and offices held. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Additional Information

Other Qualifications
Summarize special job related skills and qualifications acquired from employment or other experience.

Specialized skills (Skills/Equipment Operated)
TerminalPC/MacTypewriterSpreadsheetWord ProcessingShorthand
List machinery:
Other:

State any additional information you feel may be helpful to us in considering your application.

Note to applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Can you perform the essential functions of the job, for which you are applying, either with or without reasonable accommodation? YesNo

SECTION 4 of 4

Personal/Professional References

Name:
Phone Number:
Best time to call:
Occupation:

Name:
Phone Number:
Best time to call:
Occupation:

Name:
Phone Number:
Best time to call:
Occupation:

Applicant's Statement

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

YesNo

Electronic Signature:

Date: