General Information
Date:
First Name:
Last Name:
Middle Initial:
Email:
Other names used: Yes No
If yes please provide:
Street:
City:
State:
Zipcode:
Phone Number:
Are you 18 years old? Yes No
If offered employment will you be able to provide proof of identity and eligibility to work in the U.S. as required by federal law? Yes No
Position Information
Position Desired:
Date Available:
Salary Desired:
Are you currently employed? Yes No
If yes, should we notify you prior to contacting your employer? Yes No
Education Information
High School
Name and Location:
No. of years completed:
Did you Graduate?
College
Name and Location:
No. of years completed:
Did you Graduate?
Trade or Business
Name and Location:
No. of years completed:
Did you Graduate?
Background Information
Have you been convicted of a crime? Yes No
If yes, please provide date(s) and describe nature of the conviction. (A conviction will not necessarily disqualify you for employment. The company will consider the seriousness and type of offense, its relationship to the position for which you are applying and the date of conviction.)
Have you ever been discharged from any position? (excluding layoffs) Yes No
If yes, please explain
Have you ever been asked to resign from any position? Yes No
If yes, please explain
Employment History
(List the last four consecutive employers starting with your most recent or present employer. Resumes may not be substituted for completing this portion of the application.)
Employer:
Type of Business:
Address:
Phone number:
Position Held:
Last Salary:
Dates of Employment From:
Dates of Employment To:
Primary Responsibilities:
Reason for Leaving:
Employer:
Type of Business:
Address:
Phone number:
Position Held:
Last Salary:
Dates of Employment From:
Dates of Employment To:
Primary Responsibilities:
Reason for Leaving:
Employer:
Type of Business:
Address:
Phone number:
Position Held:
Last Salary:
Dates of Employment From:
Dates of Employment To:
Primary Responsibilities:
Reason for Leaving:
Employer:
Type of Business:
Address:
Phone number:
Position Held:
Last Salary:
Dates of Employment From:
Dates of Employment To:
Primary Responsibilities:
Reason for Leaving:
References
Please provide the names of three people not related to you who you have known at least 3 years. (Preferably people with whom you have a professional working relationship.)
Name:
Address/Phone Number:
Business:
Years Acquainted:
Name:
Address/Phone Number:
Business:
Years Acquainted:
Name:
Address/Phone Number:
Business:
Years Acquainted:
Please read before signing
Accuracy/Verification of Information
I promise that the information provided in this Application (and accompanying resume, if any) is true and complete, to the best of my knowledge, and I understand that any false information or significant omissions may disqualify me from further consideration for employment, and may be justification for my dismissal from employment, if discovered at a later date.
I authorize the investigation of all statements contained in this application (and accompanying resume, if any). I also authorize the Company to contact my references and past employers to obtain information concerning my past experiences, education and personal character.
I authorize any person, school, current employers, past employer(s), organizations and agencies to provide the Company with relevant information and opinion that may be used in employment decisions. In consideration of the Company’s review of this application, I release it and all providers of information from any liability as a result of furnishing and receiving this information.
Conditions of employment if offered
I understand that this application is not intended to be a contract of employment. I understand and agree that, if hired, my employment is for no definite period of time, and may be terminated at any time. I understand that the company can change wages, benefits and working conditions at any time and agree that, if employed, I will comply with the Company’s work rules.
I have read and understood this information.
Signature:
Date:
