Application for Employment

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department

Position(s) applied for    Date of application

Last name    First name    Middle name

Social Security # (XXX-XX-XX)

Address: Street    City

State    Zip Code

Telephone #      Mobile/Beeper/Other Phone #  

E-mail

If you are under 18, and it is required, can you furnish a work permit?  Yes   No

If no, please explain

Have you ever been employed here before? Yes   No

Are you legally eligible for employment in this country?  Yes   No

Date available for work    What is desired salary range? $ per

Type of employment desired
Full-Time   Part-Time   Temporary    Seasonal    Educational Co-Op

Are you able to meet the attendance requirements of the position?  Yes   No

Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?  Yes   No

If yes, please provide date(s) and details


ANSWERING "YES" TO THESE QUESTIONS DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT. FACTORS SUCH DATE OF THE DEFENSE, SEROUSNESS AND NATURE OF THE VIOLATION, REHABILITATION AND POSITION APPLES FOR WILL BE TAKEN INTO ACCOUNT

Driver's license number if driving is an essential job function
  State

Employment History
Provide the following information of your post four (4) employers, assignments or volunteer activities, starting with the most recent.
Employer #1
From    To      Employer

Telephone #  

Starting job title / Final job title

Address

Immediate supervisor and title

Summarize the nature of work performed and job responsibilities

May we contact for reference? Yes   No   Later

Reason for leaving

Hourly rate / salary:    Start $    Per    Final $    Per
Employer #2
From    To      Employer

Telephone #  

Starting job title / Final job title

Address

Immediate supervisor and title

Summarize the nature of work performed and job responsibilities

May we contact for reference? Yes   No   Later

Reason for leaving

Hourly rate / salary:    Start $    Per    Final $    Per
Employer #3
From    To      Employer

Telephone #  

Starting job title / Final job title

Address

Immediate supervisor and title

Summarize the nature of work performed and job responsibilities

May we contact for reference? Yes   No   Later

Reason for leaving

Hourly rate / salary:    Start $    Per    Final $    Per
Employer #4
From    To      Employer

Telephone #  

Starting job title / Final job title

Address

Immediate supervisor and title

Summarize the nature of work performed and job responsibilities

May we contact for reference? Yes   No   Later

Reason for leaving

Hourly rate / salary:    Start $    Per    Final $    Per
AN EQUAL OPPORTUNITY EMPLOYER
Skills and Qualifications
Summarize any training, skills, licenses and / or certificates that may qualify you as being able to perform job-related in the position for which you are applying.

Educational Background (if job related)
Name and location Number of years
completed 		Did you graduate? Course of study
High School
College
Other
References
Name Telephone Number of
years known
Applicant Statement

I certify that information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will besufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (person and professional), employers. Public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking. Gathering and using information in the employment process and all other persons, corporations or organizations for furnishing such information about me

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basic prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized so make any assurances to the country and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employers president

I also understand that if I am hired be required to privide proof of identity and legal authority to week in the United States and that federal immigrations laws require me to complete an I-9 Form in this regard