Apply

Last Name:

First Name:

Middle Name:

Phone:
() –

Email:

Date of Birth:
//

Present Street Address:

City:

ZIP:

State:

Are you a U.S. resident or can you furnish proof of employment eligibility? YESNO

Have you ever applied here before? YESNO

If yes, when?

Were you ever employed here? YESNO

If yes, when?

Are you now or do you expect to be engaged in any other business or employment? YESNO

Days available to work
MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Employment desired
Full-Time ONLYPart-Time ONLYFull OR Part Time

How many hours can you work weekly?

Can you work nights? YESNO

When could you start work?

HAVE YOU EVER BEEN CONVICTED OF A CRIME? (except a minor traffic violation)
YESNO

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

Education

	Type of School	Name of School	Location (Complete Mailing Address)	# Yrs Complete
High School
College
Bus. or Trade School
Professional School

Work Experience

(Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.)

Employer 1
Name of Employer	Name of Supervisor	Employed From / To /
Address:	City: State:	ZIP:
Telephone: () –	Title:	Starting $: Ending $:

Employer 2
Name of Employer	Name of Supervisor	Employed From / To /
Address:	City: State:	ZIP:
Telephone: () –	Title:	Starting $: Ending $:

Employer 3
Name of Employer	Name of Supervisor	Employed From / To /
Address:	City: State:	ZIP:
Telephone: () –	Title:	Starting $: Ending $:

Employer 4
Name of Employer	Name of Supervisor	Employed From / To /
Address:	City: State:	ZIP:
Telephone: () –	Title:	Starting $: Ending $:

Are you presently employed? YESNO

If yes, may we contact your present employer? YESNO

Have you ever been fired from a job or asked to resign?
YESNO

If yes, please explain:

Military

Have you ever been in the armed forces?
YESNO

Are you now a member of the National Guard or Reserves?
YESNO

Specialty

Dates of Service

Type of Discharge

Special Skills

What skills or additional training do you have that are related to the job for which you are applying?

What machines or equipment can you operate that are related to the job for which you are applying?

DO YOU HAVE A DRIVER’S LICENSE? YESNO
What is your means of transportation to work?

Driver’s License #:

State of issue:

Expiration Date: //

Operator:

Commercial (CDL):

Have you had any accidents during the past three years? YESNO

If so, how many?

Have you had any moving violations during the past three years? YESNO

If so, how many?

Please list three references other than relatives or previous employers

Name: Phone: () –

Relation: How long have you known this person? years

Name: Phone: () –

Relation: How long have you known this person? years

Name: Phone: () –

Relation: How long have you known this person? years

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space bellow to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

AFFIDAVIT

PLEASE READ EACH STATEMENT CAREFULLY BEFORE CONFIRMING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have the right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.

I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer (except as previously noted), past employers and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

I understand that I may be required to successfully pass a drug screening examination. I hereby consent to a pre and/or post employment drug screen as a condition of employment, if required.

I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARENTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED BY THE EMPLOYER AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE.

I have read, understand, and by confirming I consent to these statements.

This application for employment will remain active for a limited time. Ask the organization representative for details.