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NOTICE: ALL INFORMATION SUBMITTED BY YOU WILL BE KEPT IN STRICT CONFIDENCE NOT RELEASED TO ANYONE OUTSIDE THE CORPORATION AND WILL BE ACCESSABLE ONLY BY THOSE IN MANAGEMENT WHO ARE DIRECTLY INVOLVED IN THIS JOB APPLICATION EVALUATION AND NO ONE ELSE

PLEASE ANSWER ALL ITEMS CAREFULLY and COMPLETELY

Position Applied For: Date of Application:

How Did You Learn About Us?: Ad

If other, please specify:

Personal Information

First / Middle / Last Name:

Street:

City: ST: Zip Code:
Cell Phone: Home Phone:
E-mail:

Birthday Month / Day / Year (nnnn)

Social Security Number:

Employment Preconditions
If you are 18 years old can you provide required proof of your elegibility to work? YES NO
Do you have a valid drivers license? YES NO
If YES please provide Drivers License#: In state of:
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? YES NO
On what date would you be available for work?

Are you able to work: Full Time Overtime Part Time Shift Work Temporary
Are you currently on "lay-off" status and subject to recall? YES NO
Can you travel if a job requires it? YES NO

Have you ever been convicted of a crime?

 YES NO

If yes, please explain:

Conviction will not necessarily disqualify an applicant from employment

Education
 

High Schools, Technical Schools & Pre-College Level
Name of School Attended
City
State
First Year
Last Year
Field of Study
GPA
Diploma or Degree
Year
For the above schools list the Following:
Favorite Subjects:
Honors/Awards:
Sports/clubs/Other Activity:
 

College & Graduate Level
Name of School Attended
City
State
First Year
Last Year
Field of Study
GPA
Diploma or Degree
Year
List Other Special Training Certificates or Licenses Received:
Do you speak, read or write any foreign languages? YES NO
If YES LIST NAME below and indicate either "Fluent", "Fair" or "Limited":  

List Professional, Trade or Civic Activities and any Offices Held - You may exclude memberships which would reveal religion, national origin, age ancestry or handicap or other protected status.

Job Experience

List in chronological order beginning with your present or last job, include any military job related experience and any volunteer activities (you may exclude organizations which indicate race, religion, national origin, handicap or other protected status). Indicate STARTING and ENDING Pay/Hr below Mo/Yr.

Employer #1 City State Phone Supervisor
Job Title
Reason for Leaving:
 
Date Started: Starting Pay/Hr:
Date Ended: Ending Pay/Hr:
 
Employer #2 City State Phone Supervisor
Job Title
Reason for Leaving:
 
Date Started: Starting Pay/Hr:
Date Ended: Ending Pay/Hr:
 
Employer #3 City State Phone Supervisor
Job Title
Reason for Leaving:
 
Date Started: Starting Pay/Hr:
Date Ended: Ending Pay/Hr:
 
Employer #4 City State Phone Supervisor
Job Title
Reason for Leaving:
 
Date Started: Starting Pay/Hr:
Date Ended: Ending Pay/Hr:
 

Additional Qualifications & Information Volunteered

Are you in any way physically or otherwise unable to perform or limited in the performance of the job for which you are applying?

YES NO

If YES, please describe:

Have you received workers compensation payments for a job related injury or been unable to work due to injury in the last 7 years?

YES NO

If YES, please describe:

Please list any other special qualifications or skills acquired from any other experience or additional jobs held that are not already listed or any additional personal information you would like to add:

Applicant's Statement and Release:

I certify that the 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 an employment decision. In connection with my application and as a condition of continuing employment,

I understand that investigative background inquiries may be made on me including previous employers, schools, consumer credit, criminal convictions, motor vehicle, insurance claims and other reports. These reports will include information as to my character, work habits, performance, education, compensation, and experience along with reasons for termination of employment.

I authorize without reservation, any party or agency contacted to furnish the above information and release all parties from liability and responsibility for doing so.

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 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, policies and regulations of the employer. This application 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.

 

Please agree to submit Date: