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Employment

Name:
Email:
Address:
City:
State:
Zip:
Phone:
Alternate Phone:
If at present address less than one year,
please provide your previous address:
Are you over the age of 18?: 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?

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?

 
 

Do you intend to remain permanently in the U.S.?

 
Position applying for:
How soon could you report to work?:
What days and hours if part time? Days:
Hours - From:
To:
EDUCATION  
Type of School Name and Address Course Majored In Degree or Diploma
High School
College
Trade or Business College
   
EMPLOYMENT HISTORY  

Have you applied for a job with us before?

 

Have you ever worked for us before?

 
How did you come to apply? If Other then where:

Have you bee convicted of a crime except a minor traffic violation?:

 

 If yes, 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?:

 

 If so, please explain:

Does present employer know you plan employment change?:

 

 Why do you desire to make a change?:

Have you ever held a position of trust (handling money or confidential material)?

 

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 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 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 of Employer:
 Phone:
Immediate Supervisor (Name & Position):
 Date Hired:
 Starting Rate:
Your Job Title & Duties:
 Date Left:

 Last Rate:
Reason for Leaving:
4. Name & Address 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?:

If yes, date active duty started:

Which service?:

Which branch of that service?:
 Starting rank?:
Final rank?:     
What were your duties?:
  
REFERENCES
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."
Your Name: Today's Date: