Application for Employment

PERSONAL DATA

Name(Required)

First (Legal) Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Telephone(Required)

Mobile Telephone(Required)

Email Address(Required)

GENERAL DATA

Are you 18 years or older?(Required)

Yes

Are you a U.S. citizen?(Required)

Yes

If you are not a U.S. citizen, do you have the legal right to remain permanently in the U.S.?(Required)

Yes

Are you authorized to work in the United States?(Required)

Yes

Have you been previously employed here?(Required)

Yes

If yes, date(s):(Required)

Supervisor name(s):(Required)

Have you filed an application before?(Required)

Yes

If yes, date(s):(Required)

List any friends or relatives working here:

EMPLOYMENT DESIRED

Position(s) applied for:(Required)

Kind of work sought:(Required)

Full time

Part time

Salary/hourly wage desired:(Required)

Available start date:(Required)

Please specify days desired:(Required)

Days, hours, shifts vary depending on needs of business. Preferences are not guaranteed.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Desired start time:(Required)

Desired end time:(Required)

EMPLOYMENT DATA

Most Recent Employer

(1) Company name:

City

State

Position title:

Start and end dates (mo/year):

Reason for leaving:

Describe responsibilities:

Starting salary / Hourly wage:

Ending salary / Hourly wage:

May we contact this employer?

Yes

Supervisor's full name:

Supervisor's position title:

Supervisor's number:

Explain any period between positions:

Second Most Recent Employer

(2) Company name:

City

State

Position title:

Start and end dates (mo/year):

Reason for leaving:

Describe responsibilities:

Starting salary / Hourly wage:

Ending salary / Hourly wage:

May we contact this employer?

Yes

Supervisor's full name:

Supervisor's position title:

Supervisor's number:

Explain any period between positions:

Third Most Recent Employer

(3) Company name:

City

State

Position title:

Start and end dates (mo/year):

Reason for leaving:

Describe responsibilities:

Starting salary / Hourly wage:

Ending salary / Hourly wage:

May we contact this employer?

Yes

Supervisor's full name:

Supervisor's position title:

Supervisor's number:

Explain any period between positions:

Note: If you wish to describe additional employment, attach the above information for each position in a separate document and upload the document at the end of the application form.

EDUCATIONAL DATA

High School

School name:

School address:

Street Address Address Line 2 City State ZIP Code

Graduated:

Yes

Currently attending

Diploma/Degree title and major:

College

School name:

School address:

Street Address Address Line 2 City State ZIP Code

Graduated:

Yes

Currently attending

Diploma/Degree title and major:

Graduate School

School name:

School address:

Street Address Address Line 2 City State ZIP Code

Graduated:

Yes

Currently attending

Diploma/Degree title and major:

Other

Please specify.

School name:

School address:

Street Address Address Line 2 City State ZIP Code

Graduated:

Yes

Currently attending

Diploma/Degree title and major:

REFERENCES

Do not include relatives or former employers.

Reference #1

Name:

Years Acquainted:

Telephone Number:

Company:

Position title and relationship:

Reference #2

Name:

Years Acquainted:

Telephone Number:

Company:

Position title and relationship:

Reference #3

Name:

Years Acquainted:

Telephone Number:

Company:

Position title and relationship:

MILITARY SERVICE RECORD

Have you had any experience in the Armed Forces of the United States or in a State National Guard?(Required)

Yes

What branch?(Required)

Rank at discharge:(Required)

Date of discharge:(Required)

Are you in the reserves?(Required)

Yes

Date obligation ends:(Required)

Special/technical training:(Required)

ADDITIONAL INFORMATION

Have you ever been convicted of an ordinance violation, misdemeanor, or felony within the last 10 years?(Required)

Yes

If so, where, when, and explain the nature of the offense.(Required)

Do you have a valid driver’s license?(Required)

Yes

License number:(Required)

State:(Required)

List professional, trade, business or civic activities and offices held, excluding groups, the name or character of which indicate race, color, religion, sex, national origin, handicap, marital or veterans status.

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

Do you have any special training, skills, qualifications or other experiences that relate to the position(s) applied for?

How did you hear about us?

ADDITIONAL DOCUMENTS

Use this section to upload a resume and/or any additional documents.

File

Drop files here or

Accepted file types: doc, docx, pdf, pages, Max. file size: 5 MB, Max. files: 10.

AUTHORIZATION AND UNDERSTANDING

Upon the signing of this application, I represent that all the information now or hereafter given by me in support of my application for employment is true and complete. I authorize you to verify any of the information concerning my employment, education, credit or medical history with the appropriate individuals, companies, institutions or agencies and I authorize them to release such information as you require, including my prior disciplinary employment record, without any obligation to give me written notice of such disclosure. I also authorize you to release any information requested by any of my prospective or subsequent employers without any obligation to give me written notice of such disclosure. I hereby release you and them from any liability whatsoever as a result of any such inquiries and disclosures. I agree that any false information in support of my application may subject me to discharge at any time during the period of my employment. If hired, I agree I will serve at the will of the company and I agree that I shall be bound by the rules, policies, regulations and terms and conditions of employment of the company relationship, with or without cause, at any time for any reason. I hereby authorize the company to deduct from each and every period of my pay any amounts necessary to offset any damages caused by me or the value of property or money entrusted to me by, or owed by me to the company during the course of my employment. I agree that these arrangements may only be altered in writing directed to me personally by the President of the company. I agree that any action or suit against the firm arising out of my employment, including but limited to claims arising under state or federal civil rights statues, must be brought within 180 days of the event giving rise to the claims or be forever barred. I waive any limitation periods to the contrary. I further agree that if I should bring any action or claim arising out of my employment against the company in which the company prevails, I will pay to the company any and all costs incurred by the company in defense of said claims or actions, including attorney fees. I further agree that my employment is conditional until such time as the results of my pre-employment physical (if such physical is required) are known.

Applicant signature:(Required)