APPLICATION FOR EMPLOYMENT
ALL POTENTIAL EMPLOYEES ARE EVALUATED WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, MARITAL OR VETERAN STATUS, THE PRESENCE OF A NON-JOB RELATED HANDICAP OR ANY OTHER LEGALLY PROTECTED STATUS.
Position Sought: _________________________________________________________________________
How did you learn about the position? ________________________________________________________
Name_____________________________________________________________ Date__________________
Address__________________________________ City___________________ State________ Zip_________
Home Phone ____________________ Other Phone_________________
Email Address: ______________________________ Social Security Number:_________________________
Birth Date: _________________________________
On what date would you be available for work? ____________________
DesiredWage/Salary$_____________
Are you a U.S. citizen, or are you otherwise authorized to work in the U.S. without any
restriction?[ ]Yes[ ]No
Have you ever been convicted of a felony? [ ] Yes [ ] No
If yes, please describe circumstances:___________________________________________________________ _________________________________________________________________________________________
Have you ever been involuntarily terminated or asked to resign from any position of employment? [ ] Yes [ ] No
If yes, please describe circumstances: __________________________________________________________
_________________________________________________________________________________________
If selected for employment, are you willing to submit to a pre-employment drug screening test? [ ] Yes [ ] No
EDUCATION
School Name Location Years Attended Degree Received Major
Other training, certifications, or licenses held: ____________________________________________________
_________________________________________________________________________________________
List other information pertinent to the employment you are seeking: __________________________________
_________________________________________________________________________________________
EMPLOYMENT
(Most Recent First.)
1. Employer_____________________________________________ Job Title__________________________
Dates Employed______________ Prior Position Held within Company (if any): ________________________
Address_________________________________ City___________________ State________ Zip___________
Phone____________________ Job Title_______________________ Supervisor________________________
Starting Salary________________________________ Ending Salary_______________________________
Duties Performed __________________________________________________________________________
Reason for Leaving ________________________________________________________________________
2. Employer_____________________________________________ Job Title__________________________
Dates Employed______________ Prior Position Held within Company (if any): ________________________
Address_________________________________ City___________________ State________ Zip___________
Phone____________________ Job Title_______________________ Supervisor________________________
Starting Salary________________________________ Ending Salary________________________________
Duties Performed ___________________________________________________________________________
3. Employer_____________________________________________ Job Title___________________________
Dates Employed______________ Prior Position Held within Company (if any): _________________________
Address_________________________________ City___________________ State________ Zip____________
Phone____________________ Job Title_______________________ Supervisor_________________________
Starting Salary________________________________ Ending Salary_________________________________
Duties Performed ___________________________________________________________________________
Reason for Leaving _________________________________________________________________________
4. Employer_____________________________________________ Job Title___________________________
Dates Employed______________ Prior Position Held within Company (if any): _________________________
Address_________________________________ City___________________ State________ Zip____________
Phone____________________ Job Title_______________________ Supervisor__________________________
Starting Salary________________________________ Ending Salary_________________________________
Duties Performed ____________________________________________________________________________
Reason for Leaving __________________________________________________________________________
ACKNOWLEDGMENT AND AUTHORIZATION
I certify that answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in
arriving at an employment decision.
This application for employment shall be considered active for a period of time not to exceed 45 days. Any
applicant wishing to be considered for employment beyond this time period should inquire as to whether
or not applications are being accepted at that time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment
relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time
and the Employer may discharge Employee at any time with or without cause. It is further understood that
this “at will” employment relationship may not be changed by any written document or by conduct unless such
change is specifically acknowledged in writing by an authorized executive of this organization.
In the event of employment, I understand that false or misleading information given in my application or
interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations
of the employer.
_________________________________________ ___________________
Signature of Applicant Date
