Application for Employment

Personal Information

Last Name:*

First Name:*

Middle:

Date:*

Address:

City:

State:

Zip:

Business Phone:

Cell Phone

Home Phone:*

Email Address:*

What was your previous address?

How long at present address?

Years Months

Are you over 18 years of age? Yes No

Have you ever applied for employment with us? Yes No

How did you learn of our organization?

Are you legally eligible for employment in the United States? Yes No

When will you be able to work?

Are you employed now? Yes No

If so, may we inquire of your present employer? Yes No

Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by a court? Yes No

If Yes, describe in full

Are there any reasons for which you might not be able to perform the job duties (with a reasonable accommodation)? Yes No

If Yes, please explain.

Drivers Licence #

State:

Any Violations? Yes No

Education

College

Name & Location of School

Course of Study

No. of years completed

Did you graduate? Yes No

Degree or Diploma

High School

Name & Location of School

Course of Study

No. of years completed

Did you graduate? Yes No

Degree or Diploma

Trade School

Name & Location of School

Course of Study

No. of years completed

Did you graduate? Yes No

Degree or Diploma

Other

Name & Location of School

Course of Study

No. of years completed

Did you graduate? Yes No

Degree or Diploma

Military

Have you served in the U.S. Armed Forces Yes No

Employment History

Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer.

Employer 1

Company Name

Telephone

Address

Employed From: (Start Month and Year)

Employed To: (End Month and Year)

Name of Supervisor

Hourly Rate (Start)

Hourly Rate (Last)

Start Job Title and Describe Your Work

Reason for Leaving

Employer 2

Company Name

Telephone

Address

Employed From: (Start Month and Year)

Employed To: (End Month and Year)

Name of Supervisor

Hourly Rate (Start)

Hourly Rate (Last)

Start Job Title and Describe Your Work

Reason for Leaving

Employer 3

Company Name

Telephone

Address

Employed From: (Start Month and Year)

Employed To: (End Month and Year)

Name of Supervisor

Hourly Rate (Start)

Hourly Rate (Last)

Start Job Title and Describe Your Work

Reason for Leaving

Employer 4

Company Name

Telephone

Address

Employed From: (Start Month and Year)

Employed To: (End Month and Year)

Name of Supervisor

Hourly Rate (Start)

Hourly Rate (Last)

Start Job Title and Describe Your Work

Reason for Leaving

We may contact the employers listed above unless you indicate those you do not want us to contact

Do Not Contact (Company Names)

Reason

References

Give below the names of three persons not related to you, whom you have known at least one year.

Reference 1

Name

Address

Business

Years Acquainted

Reference 2

Name

Address

Business

Years Acquainted

Reference 3

Name

Address

Business

Years Acquainted

The information provided in this Application for Employment is true, correct and complete. If employed, any misstatements or omissions of fact on this application may result in my dismissal. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future.

If you decide to engage an investigative consumer reporting agency to report on my credit and personal history, I authorize you to do so.

If a report is obtained you must provide, at my request, the name and address of the agency so I may obtain from them the nature and substance of the information contained in the report.

Date: Signature (retype name)