Application for Employment

AN EQUAL OPPORTUNITY EMPLOYER

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodations to the application and/or interview process should notify a representative of the Human Resources Department.

Location
Name (Last, First Middle) Social Security Number
Present Address (Include City, State, Zip Code)
Telephone   Mobile/Beeper/Other/Phone #    E-mail Address
Position(s) applied for   Date of Application
Referral Source (Please check the appropriate category and name the source)
Walk-in School
Employee Job Fair
Advertisement Staffing Agency
Company's Website Government Employment Agency
Other Internet Other
 
If necessary, best time to call you at home is AM PM
  Will you work overtime if required? Yes No
  If no, please explain
 

Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)?

This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Yes No Need more information about the job's "essential functions" to respond

 

Driver's license number required if driving may be required in the job for which you are applying:
State

  Have you ever been bonded? Yes No
 

Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offence, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?
Yes No

 

If yes, please provide date(s) and details

 

 

 

 
May we contact you at work? Yes No
If yes, work number and best time to call:
Time: 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 No
If yes, give date(s) and position(s)
Have you ever been employed here before? Yes No
If yes, give dates From To
Are you legally eligible for employment in this country? Yes No
Date available for work
What is your desired salary range or hour rate of pay?
$ Per
Type of employment desired Full Time Part Time
Educational Co-Op Seasonal Temporary
Will you relocate if job requires it? Yes No
Will you travel if job requires it? Yes No
If they have been explained to you, are you able to meet the attendance requirements of the position? N/A Yes No

Employment History

Starting with your most recent employer, provide the following information.

Current or Most Recent
Employer Phone
Dates Employed From To
Compensation (Starting)
Hourly Salary $ per
Commission/Bonus/Other Compensation $
Compensation (Final)
Hourly Salary $ per
Commission/Bonus/Other Compensation $
Address (Street, City, State)
Job Title
Immediate Supervisor and title (for most recent position held)
Why did you leave?

May we contact them? Yes No Later

Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about your position?
1st Previous
Employer Phone
Dates Employed From To
Compensation (Starting)
Hourly Salary $ per
Commission/Bonus/Other Compensation $
Compensation (Final)
Hourly Salary $ per
Commission/Bonus/Other Compensation $
Address (Street, City, State)
Job Title
Immediate Supervisor and title (for most recent position held)
Why did you leave?

May we contact them? Yes No Later

Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about your position?
2nd Previous
Employer Phone
Dates Employed From To
Compensation (Starting)
Hourly Salary $ per
Commission/Bonus/Other Compensation $
Compensation (Final)
Hourly Salary $ per
Commission/Bonus/Other Compensation $
Address (Street, City, State)
Job Title
Immediate Supervisor and title (for most recent position held)
Why did you leave?

May we contact them? Yes No Later

Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about your position?
3rd Previous
Employer Phone
Dates Employed From To
Compensation (Starting)
Hourly Salary $ per
Commission/Bonus/Other Compensation $
Compensation (Final)
Hourly Salary $ per
Commission/Bonus/Other Compensation $
Address (Street, City, State)
Job Title
Immediate Supervisor and title (for most recent position held)
Why did you leave?

May we contact them? Yes No Later

Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about your position?
 
Explain any gaps in your employment,other than those due to personal illness, injury, or disability.
If not addressed previously, have you ever been fired or asked to resign from a job? Yes No
If yes, please explain:
 

Skills and Qualifications

Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying.
Computer Skills (Check appropriate boxes. Include software titles and year of experience.)
Word Processing Years Internet Years
Spreadsheet Years Other Years
Presentation Years Other Years
Email Years Other Years

Educational Background

Starting with your most recent school attended, provide the following information.

School (include City and State) Years Completed Completed GPA
Class Rank 		Major/Minor

Diploma
Degree
Certificate
Other
GED

Diploma
Degree
Certificate
Other
GED

Diploma
Degree
Certificate
Other
GED

Diploma
Degree
Certificate
Other
GED

References

List name and telephone number of three business/work references.

Name Title Relationship to You Phone-Work/Home Number of Years Known

Related Information

To what job-related organizations (professional, trade, etc.) do you belong?

Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.

Organization Offices Held

List special accomplishments, publications, awards, etc.

Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.

In your current or a prior job, have you ever written instructions or directions to be followed by employees or customers? Yes No Not Applicable
If yes, please explain:
Is there any other job-related information you want us to know about you?

Application Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 90 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and 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 with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered. Yes

DO NOT CLICK YES UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement and will be asked to sign my application if I am called in for an interview. Yes