APPLICATION FOR EMPLOYMENT
An Equal Opportunity Employer
(Application will remain active for 30 days)
Position Applied For: __________________________________________ Referral Source__________________________________
NAME: _______________________________________________________ SOCIAL SECURITY #: ______________________
Last
First
M.I.
ADDRESS: _________________________________________________________________ PHONE: (_____) _______________
Street
City
State Zip
Are you at least 18 years of age?
Yes No
Are you a U.S. Citizen or legally
Yes No
authorized to work in the U.S.?
Date you are able to start work: ________________________
May we contact your current employer?
Yes No
Are you on layoff status or subject
to recall elsewhere?
Yes No
Pay Expected: $_________________ per ________________
If hired, how long do you plan to continue
working for the company? _____________________________
Do you wish to work: Full-time
Part-time
Temporary
Are you willing and available to work?
On call
Days
Evenings
Nights
Overtime
Weekends
Holidays
If applying for a job which requires one,
do you have a valid driver's license?
Yes No
Do you smoke?
Yes No
Have you been convicted of a crime or released
from prison in the last 7 years? *
Yes No
If so, explain ______________________________________
__________________________________________________
* A "yes" answer will not necessarily bar applicant from employment.
Have you previously applied with us?
Yes No
When ____________________________________________
Have you previously worked with us?
Yes No
When ____________________________________________
Are any of your records under a different name? Yes No
If so, what name ___________________________________
Do you have any relatives working for us?
Yes No
If so, who? ________________________________________
Is there any reason you might be unable to
meet our attendance requirements?
Yes No
If yes, please explain _______________________________
EDUCATION/
TRAINING
Name and Location of School
Did You
Graduate?
Subjects Studied
High School
College
Other Training
(particularly that led to
license or certification)
Are you taking or do you plan to take any additional education? If so, what? ______________________________________________
____________________________________________________________________________________________________________
SKILLS / ABILITIES:
List any machines you are skilled in using: _________________________________________________________________________
____________________________________________________________________________________________________________
List any skills or abilities you have which are pertinent to the position, including hobbies or related interests: ____________________
____________________________________________________________________________________________________________
JOB REQUIREMENTS: Do you believe you are capable of performing, with or without accommodation,
"the essential functions of the job" for which you are applying?
Yes No
(over)
,
PLEASE LIST WORK EXPERIENCE, INCLUDING MILITARY AND VOLUNTEER EXPERIENCE
Present or Last Employer:
Address and Phone:
Start Date:
Leaving Date:
Supervisor:
Rate of Pay $
Job Duties:
Why Did You Leave?
Previous Employer :
Address and Phone:
Start Date:
Leaving Date:
Supervisor:
Rate of Pay $
Job Duties:
Why Did You Leave?
Previous Employer :
Address and Phone:
Start Date:
Leaving Date:
Supervisor:
Rate of Pay $
Job Duties:
Why Did You Leave?
PERSONAL REFERENCES
Name:
Phone ( )
Address:
Occupation:
How Long Known:
Name:
Phone ( )
Address:
Occupation:
How Long Known:
PLEASE READ EACH OF THE FOLLOWING ITEMS BEFORE SIGNING THIS APPLICATION
1. As a final step in the hiring process, an applicant may be subject to an employment entrance exam that may include a criminal,
driving and/or credit background check. Applicants who do not meet the company's criteria will not be considered for employment.
If a job offer is made, it may be made contingent upon the meeting this criteria.
2. I CERTIFY that the facts contained in this application are true and complete to the best of my knowledge and understand that, if
employed, false, misleading or incomplete statements on this application shall be grounds for dismissal.
3. I AUTHORIZE the company to investigate information concerning my previous employment and education. I further authorize the
release of this information to you, and I hereby release such parties from all liability for any damage that may result from furnishing
such information. I authorize this company to request a copy of my credit report from the credit bureau.
4. I UNDERSTAND and agree that my employment and compensation may be terminated at any time without prior notice, with or
without cause, at the option of the company or myself, and understand that no representative of the company, other than the
President, has authority to enter into any agreement contrary to the foregoing.
5. I UNDERSTAND that all company property must be returned and any indebtedness to the company must be paid on or before my
last day of work. I authorize the company to deduct from my final paycheck an amount necessary to satisfy any unpaid obligation.
Date _________________________ Signature of Applicant__________________________________________________________
h:/Recruiting/Application for Employment.doc
06/10/05
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