Our policy is to provide equal employment opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, ancestry, physical or mental disability, or veteran status.Education
Date ______________
Last name ________________________ First name ________________ Middle name________
Street Address __________________________________________________ _______________
City _____________________ State _______ ZIP _______
Telephone ___________________________ Social Security # ___________________________
Position applied for __________________________________________
How did you hear of this opening? __________________________________________
When can you start? _____________________ Desired Wage $______________
Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation.) q Yes q No
Are you looking for full-time employment? q Yes q No
If no, what hours are you available? ______________
Are you willing to work swing shift? q Yes q No
Are you willing to work graveyard? q Yes q No
Have you ever been convicted of a felony? (This will not necessarily affect your application.) q Yes q No
If yes, please describe conditions. __________________________________________________
__________________________________________________ ____________________________
__________________________________________________ ____________________________
__________________________________________________ ____________________________
__________________________________________________ ____________________________
School Name and Location Year Major Degree
High School ________________________________________ ______ ______ ______
College ___________________________________________ ______ ______ ______
College ___________________________________________ ______ ______ ______
Post-College _______________________________________ ______ ______ ______
Other Training ______________________________________ ______ ______ ______
In addition to your work history, are there other skills, qualifications, or experience that we should consider? __________________________________________________ ____________________________
__________________________________________________ ____________________________
__________________________________________________ ____________________________
__________________________________________________ ____________________________
__________________________________________________ ____________________________
__________________________________________________ ____________________________
Employment History (Start with most recent employer)
Company Name __________________________________________________ ______________
Address ____________________________________ Telephone _________________________
Date Started ___________ Starting Wage ____________ Starting Position ________________
Date Ended _____________ Ending Wage ____________ Ending Position ________________
Name of Supervisor ____________________________________
May we contact? q Yes q No
Responsibilities __________________________________________________ _____________
__________________________________________________ ___________________________
Reason for leaving __________________________________________________ ____________
Company Name __________________________________________________ ______________
Address ________________________________________ Telephone _____________________
Date Started ____________ Starting Wage ____________ Starting Position _______________
Date Ended _____________ Ending Wage ____________ Ending Position ________________
Name of Supervisor ____________________________________
May we contact? q Yes q No
Responsibilities __________________________________________________ ______________
__________________________________________________ ____________________________
Reason for leaving __________________________________________________ ____________
Company Name __________________________________________________ _____________
Address _______________________________________ Telephone ______________________
Date Started ____________ Starting Wage ____________ Starting Position _______________
Date Ended _____________ Ending Wage ____________ Ending Position ________________
Name of Supervisor ____________________________________
May we contact? q Yes q No
Responsibilities __________________________________________________ ______________
__________________________________________________ ____________________________
Reason for leaving __________________________________________________ ____________
Company Name __________________________________________________ ______________
Address _______________________________________ Telephone ______________________
Date Started ____________ Starting Wage ____________ Starting Position _______________
Date Ended _____________ Ending Wage ____________ Ending Position ________________
Name of Supervisor ____________________________________
May we contact? q Yes q No
Responsibilities __________________________________________________ ______________
__________________________________________________ ____________________________
Reason for leaving __________________________________________________ ____________
Attach additional information if necessary.
I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements on this application shall be considered sufficient cause for dismissal. This company is hereby authorized to make any investigations of my prior educational and employment history.
I understand that employment at this company is “at will,” which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager, or executive of this company, other than the president, has any authority to alter the foregoing.
Signature_________________________________________ ______ Date _________________
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