APPLICATION FOR EMPLOYMENT
All statements made by applicants for employment on this application form will be
carefully checked for accuracy. We offer equal employment opportunities to all persons
without regard to race, creed, religious denomination, age, national origin, color,
handicap, status with regard to public assistance, disability, sexual orientation, marital
status, sex, membership or activity in a local commission or political conviction. The use
of this form does not mean there are positions open and does not obligate us in any way.
This application will remain on active file for a period of 12 months from date of
application.
PERSONAL INFORMATION
Name (Print) ___________________________________________Maiden or
other: ___________________________
Date:_____________________________
Social Security Number: _______________________________ Home Phone:
_____________________________
Other Phone:______________________________
Present address _______________________________________________________ City, State,
Zip:____________________________________________
If at present address less than one year, please give previous
address_______________________________________________________________________________________
Are you over the age of 18? [] Yes [] No If no, employment is subject to verification that
you are of minimum legal age.
What languages can you read, speak, and write fluently?
________________________________________________________________________________________
Are you a citizen of the United States? [] Yes [] No If not a citizen of the U.S., can you
provide Form 1-151 or Form 1-94 as proof that you can legally be employed in the Unites
States? [] Yes [] No Do you intend to remain permanently in the U.S.? [] Yes [] No
Position applied for _________________________________________ How soon could you report
to work? _________________________
Type of employment [] Full Time [] Part Time [] Temporary
What days and hours if part time? Days: Su Mo Tu We Th Fr Sa Hours From: (
) [] AM [] PM To: ( ) [] AM [] PM
EDUCATION
| Type of School |
Name and Address of School |
Courses Majored In |
Degree or diploma |
| High School |
|
|
|
| College |
|
|
|
| Trade or Business College |
|
|
|
EMPLOYMENT HISTORY
Have you applied for a job with us before? [] Yes [] No Have you ever worked for us
before? [] Yes [] No
How did you come to apply? [] Employee Referral [] Former Employee [] High School
Recruitment
[] College Recruitment [] Newspaper Ad [] Walk-in [] Other
___________________________________________________________________________
Have you ever been convicted of a crime except a minor traffic violation? [] Yes [] No If
so, state date, court and place where offense occurred.
(A criminal record does not constitute an automatic bar to employment and will be
considered only as it relates to the job in question)
Have you ever been discharged or requested to resign from a position? [] Yes [] No If so,
please explain. _______________________________________________
Does present employer know you plan employment change? [] Yes [] No Why do you desire to
make a change? _______________________________________
Have you ever held a position of trust (handling money or confidential material)? [] Yes
[] No How much time have you lost from work during this past year?
__________________________________________________________________________________
PRIOR WORK RECORD (Start with the most recent or
present employer)
| 1.
Name, Address & Phone of Employer |
Phone |
| Immediate Supervisor (Name &
Position) |
Date Hired |
Starting Rate |
| Your Job Title & Duties |
Date Left |
Last Rate |
| Reason for Leaving |
|
| 2.
Name, Address & Phone of Employer |
Phone |
| Immediate Supervisor (Name &
Position) |
Date Hired |
Starting Rate |
| Your Job Title & Duties |
Date Left |
Last Rate |
| Reason for Leaving |
| 3.
Name, Address & Phone of Employer |
Phone |
| Immediate Supervisor (Name &
Position) |
Date Hired |
Starting Rate |
| Your Job Title & Duties |
Date Left |
Last Rate |
| Reason for Leaving |
SERVICE IN U.S. ARMED FORCES
Have you served in the U.S. Armed Forces? []Yes []No If yes, date
active duty started______________________ Which service? ____________________
What branch of that service? ___________________ Starting
rank?_______________ Final rank? __________________
What were your
duties?________________________________________________________________
REFERENCES
(DO NOT LIST RELATIVES OR FORMER EMPLOYERS)
Name_____________________Address_______________________________________
Occupation______________
Name_____________________Address_______________________________________
Occupation______________
Name_____________________Address_______________________________________
Occupation______________
JOB APPLICANT'S AGREEMENT AND CERTIFICATION
"I certify that the information given by me in this application is
true in all respects, and I agree that if employed and it is found to be false in any way,
that I may be subject to dismissal without notice, if and when it is discovered. I
authorize the use of any information in this application to verify my statements, and I
authorize the past employers, doctors, all references, and any other persons to answer all
questions asked concerning my ability, character, reputation, and previous employment
record. I release all such persons from any liability or damages on account of having
furnished such information. I further agree, if employed, that I am to work faithfully and
diligently, to be careful and avoid accidents, to come to work promptly, and I am not to
be absent for any reason without prior notice to my supervisor, and that employment is
terminable at the will of either the employee or employer.
I agree to submit to a physical examination whenever
requested and, if employed, I agree to observe all present and subsequently issued
personnel policies and rules. These rules and policies are intended to guide the
organization in its relationship with its employees. It is not a contract of employment,
and I do not construe it as such. Policies and rules which are issued are not conditions
of employment. I understand that the employer may revise policies or procedures, in whole
or in part, at any time, with or without notice."
Signature of Applicant___________________________________________
Date_______________