Applicant Name
Primary Phone
Position Applied For
Email
Home Address - Street
City
State
Zip
How long have you lived here?
Submission Date
Type of employment desired? Full-time / Part-time (Specify Hours)
Desired Wage (Hourly/Salary)?
Date on which you can start work if hired:
If Yes, please provide details
If applicable, list any other names by which you have been known which may be necessary to allow us to confirm your work and educational record. For example, change of name, use of an assumed name, nickname, etc
High School
Course of Study or Major
Graduate? Y/N
#Years completed
Honors Received
College
Course of Study or Major
Graduate? Y/N
#Years completed
Honors Received
Graduate/Professional
Course of Study or Major
Graduate? Y/N
#Years completed
Honors Received
Trade or correspondence
Course of Study or Major
Graduate? Y/N
#Years completed
Honors Received
Please list the names of your present and/or previous employers in chronological order with the present or most recent employer listed first.
Provide information for at least the most recent ten (10) year period. Attach additional sheets if needed.
If self- employed, supply firm name and business references. You may include any verifiable work performed on a volunteer basis, internships, or military service.
Your failure to completely respond to each inquiry may disqualify you for consideration from employment.
Do not answer “see resume.”
If “Yes” How many times?
If “Yes” Please explain the circumstance(s).
If “Yes” How many times?
If “Yes” Please explain the circumstance(s).
If “Yes” How many times?
If “Yes” Please explain the circumstance(s).
Employer #1
Company Name
Primary Phone #
Street Address
City
State
Zip
Type Of Business
Job Title
Dates Employed: From
Dates Employed: To
List Primary Duties
If "Yes" for what?
Reason For Leaving
How much notice did you give when resigning?
If none, explain:
Supervisor Name
If “NO” why not?
What will this employer say was the reason your employment terminated?
Employer #2
Company Name
Primary Phone #
Street Address
City
State
Zip
Type Of Business
Job Title
Dates Employed: From
Dates Employed: To
List Primary Duties
If "Yes" for what?
Reason For Leaving
How much notice did you give when resigning?
If none, explain:
Supervisor Name
If “NO” why not?
What will this employer say was the reason your employment terminated?
Employer #3
Company Name
Primary Phone #
Street Address
City
State
Zip
Type Of Business
Job Title
Dates Employed: From
Dates Employed: To
List Primary Duties
If "Yes" for what?
Reason For Leaving
How much notice did you give when resigning?
If none, explain:
Supervisor Name
If “NO” why not?
What will this employer say was the reason your employment terminated?
Please list the names of additional work-related references we may contact.
Individuals with no prior work experience may list school or volunteer-related references.
Name
Position
Company
Relationship (i.e. Supervisor, co-worker)
Primary Phone #
Please list the names of personal references who you know that we may contact. (not previous employers or relatives)
Name
Occupation
Address
Primary Phone #
# Years Known
Complete only if driving is an essential function of the job for which you are applying.
License No
Expiration
State
If you do not have a driver’s license for the state in which you currently reside, why not?
If YES Please Explain
If NO Please Explain
If YES Please Explain
Please list the names of additional work-related references we may contact.
Offense
Date
Location
Comments
THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT, REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT—EXPRESS OR IMPLIED—WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY. IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL.
I authorize the Company or its agents to confirm all statements contained in this application and/or resume as it relates to the position I am seeking to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation which may be permitted by federal, state and/or local law. If applicable and allowed by law, I will receive separate written notification regarding the Company’s intent to obtain “consumer reports.”
I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the abovementioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information. Further, if hired, I authorize the company to provide truthful information concerning my employment to future employers and hold the company harmless for providing such information.
If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Company. I also understand this Company employs only individuals who are legally eligible to work in the United States.
I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver’s license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside.
“I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE."
PLEASE ONLY SIGN ONCE YOU HAVE READ ALL OF THE INFORMATION CONTAINED IN THE APPLICATION.
Applicant Signature
Date
If the applicant is a minor, the foregoing release and consent must be signed by the applicant’s parent or legal guardian. Signature by the applicant’s parent or legal guardian constitutes acknowledgment by the applicant and the parent or legal guardian that the Company, to the extent permitted by federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate test results to Company personnel who need to know, the applicant, and the applicant’s legal guardian.
Parent / Guardian Signature
Witness Signature
Send
