Employment Application

Position(s) Applied For: *

How did you learn about us?:

 Advertisement  Friend  Walk-In  Employment Agency  Relative
 Other

First Name: *

Middle Initial: *

Last Name: *

Address: *

Street:

City:

State/Prov:

Zip:

Telephone Number(s): *

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

 Yes  No

Have you ever filed an application with us before?

 Yes  No

If yes, give date:

Have you ever been employed with us before?

 Yes  No

If yes, give date:

Are you currently employed?

 Yes  No

May we contact your present employer?

 Yes  No

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

 Yes  No

On what date would you be available for work: *

Are you available to work: *

 Full Time  Part Time  Shift Work  Temporary

What shift/hours are you available to work? *

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

 Yes  No

Can you travel if a job requires it?

 Yes  No

Education History

High School Name and Location:

Number of Years Completed:

 9th Grade  10th Grade  11th Grade  Graduate

Type of Diploma/Degree:

Describe Course of Study:

Undergraduate College/University Name and Location:

Number of Years Completed:

 1  2  3  Graduate

Type of Diploma/Degree:

Describe Course of Study:

Graduate/Professional Name and Location:

Number of Years Completed:

 1  2  3  Graduate

Type of Diploma/Degree:

Describe Course of Study:

Describe any specialized training, apprenticeshp, skills and extra-curricular activities:

Describe any honors you have received:

Describe any additional information you feel may be helpful to us in considering your application:

Foreign Languages

Indicate any foreign languages you can speak, read and/or write.

Languages you can speak:

 Fluent  Good  Fair

Languages you can read:

 Fluent  Good  Fair

Languages you can write:

 Fluent  Good  Fair

Offices Held

List professional, trade, business or civic activities and offices held:
You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or handicap or other protected status.

REFERENCES

Give name, address and telephone number of three (3) references who are not related to you and are not previous employers.

Reference #1 Name (first and last): *

Reference #1 Address:

Street:

City:

State/Prov:

Zip:

Reference #1 Telephone Number: *

Reference #2 Name (first and last): *

Reference #2 Address:

Street:

City:

State/Prov:

Zip:

Reference #2 Telephone Number: *

Reference #3 Name (first and last):

Reference #3 Address:

Street:

City:

State/Prov:

Zip:

Reference #3 Telephone Number:

Have you ever had any job-related training in the United States military?

 Yes  No

If yes, please describe:

Are you physically or otherwise unable to perform the duties of the job for which you are applying?:

 Yes  No

Employment History

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

Employer: *

Address:

Street:

City:

State/Prov:

Zip:

Telephone Number: *

Dates Employed: *

From:

To:

Job Title: *

Supervisor:

Hourly Rate/Salary:

Starting:

Final:

Work performed: *

Reason for leaving:

Employer:

Address:

Street:

City:

State/Prov:

Zip:

Telephone Number:

Dates Employed:

From:

To:

Job Title:

Supervisor:

Hourly Rate/Salary:

Starting:

Final:

Work performed:

Reason for leaving:

Employer:

Address:

Street:

City:

State/Prov:

Zip:

Telephone Number:

Dates Employed:

From:

To:

Job Title:

Supervisor:

Hourly Rate/Salary:

Starting:

Final:

Work performed:

Reason for leaving:

Employer:

Address:

Street:

City:

State/Prov:

Zip:

Telephone Number:

Dates Employed:

From:

To:

Job Title:

Supervisor:

Hourly Rate/Salary:

Starting:

Final:

Work performed:

Reason for leaving:

Special Skills and Qualifications:
Summarize special job-related skills and qualifications acquired from employment or other experience.

I certify that answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at 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 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.