Employment Application

Please complete each section EVEN IF you decide to attach a resume.

Personal Information

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Postal code *

Employment Desired

Position Applied For

Desired Pay

Are You Employed?

Yes

Date Available

Desired Hours

Full Time

Part Time

Seasonal

Education History

High School: Name & Address

Years Attended in High School?

Did you graduate High School?

Yes

Undergraduate College: Name & Address

Years Attended in Undergraduate College?

Did you graduate Undergraduate College?

Yes

Graduate Professional: Name & Address

Years Attended in Graduate Professional?

Did you graduate Graduate Professional?

Yes

Other (Specify School)

Years Attended in OTHER (school)?

Did you graduate OTHER?

Yes

List any other seminars, classes, certifications or other education not listed above which may help you qualify for this position:

Previous Employment

Employer 1

Phone Number of Employer 1

Job Title at Employer 1

Start Date at Employment 1

End Date at Employment 1

Reason for Leaving (Employer 1)

Employer 2

Phone Number of Employer 2

Job Title at Employer 2

Start Date at Employment 2

End Date at Employment 2

Reason for Leaving (Employer 2)

Employer 3

Phone Number of Employer 3

Job Title at Employer 3

Start Date at Employment 3

End Date at Employment 3

Reason for Leaving Employer 3

References

Full Name (Reference 1)

Relationship (Reference 1)

Phone Number (Reference 1)

Email (Reference 1)

Full Name (Reference 2)

Relationship (Reference 2)

Phone Number (Reference 2)

Email (Reference 2)

Full Name (Reference 3)

Relationship (Reference 3)

Phone (Reference 3)

Email (Reference 3)

Driving History

Please make a detailed list of all accidents or tickets that may appear on driving record including date of incidents.

Additional Information

Have you ever been employed with this company before? If yes, when?

Yes

Do you have any friends or relatives employed by this company? If you, please provide their names and relationship to you:

Yes

Are you currently on “lay off” status and subject to recall?

Yes

If you are under 18 years of age, can you provide proof of your eligibility to work?

Yes

If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.?

Yes

Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accommodations?

Yes

If hired, are there any accommodations the company would need to provide so that you can perform all those essential functions and duties of the position being applied for? If yes, please explain:

Yes

Have you in the last 7 years been convicted of Driving Under the Influence “(DUI)”?

Yes

If hired, do you have a reliable means of transportation to and from work?

Yes

If hired, would you be able to work overtime and/or weekends as needed?

Yes

Background Information

Have you ever, under your name or another name, been convicted of (or pleaded not contest to) a felony or misdemeanor?

Yes

Have you ever, under your name or another name, been convicted of a crime, which resulted in your being in prison and/or jail and released from prison and/or jail or paroled? If yes to either question above, please fully explain when, where and of what you were convicted and the result of the case(s).

Yes

Have you ever been convicted of a felony or misdemeanor? If yes, please explain:

Yes

Have you used illegal drugs in the last six months?

Yes

Do you take illegal drugs or medications that have not been prescribed for you? If yes, to either of the questions above, when was the last time you used illegal drugs?

Yes

Have you ever been convicted of driving under the influence? (DUI)

Yes

Do you use alcohol to the extent that it would impair your job performance?

Yes

Background Check Consent

If asked, are you willing to consent to a background check?

Yes

Background Acknowledgment

Please read each statement closely and check each acknowledging your understanding of the Background Acknowledgment.

Equal Employment Opportunity Statement - This Company is committed to the principles of equal employment opportunity and is committed to make employment decisions based on merit. We are committed to complying with all Federal, State and local laws providing for equal employment opportunities, as well as all laws related to terms and conditions of employment. The Company desires to maintain a work environment that is free of sexual harassment and discrimination due to race, religion, color, national origin, physical or mental disability, age or any other status protected by Federal, State or local laws. The Company will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless undue hardship would result for the Company.

Discrimination and Sexual Harassment Policy Statement - This company will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline, up to and including termination. Prohibited sexual harassment is defined as follows: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct is made whether explicitly or implicitly a term or condition of an individual’s employment; (2) submission to or action of such conduct by an individual is used as the basis for employment decisions affecting such individuals; or (3) such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive work environment.

Disclosure to Applicants Concerning Drug/Alcohol Testing - If you are offered a position with the Company, you will be asked to take a drug/alcohol test as a condition of employment. Your refusal to timely submit to a drug/alcohol test or your failure to pass such a test means you will not be employed by this Company. Neither the collector of specimens nor the medical professional who reviews the test results will be a Company employee. The test results will be kept confidential. The individual undergoing testing will not be directly observed while providing the specimen unless there are reasonable grounds to believe the individual may alter or substitute the specimen. Negative test results are required as a condition of employment.

Complete and Accurate Information - I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application, or any other document used to secure employment, shall be grounds for rejection of the application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

At-Will Employment - I understand and agree that if I am employed, my employment will be “at-will”, which means that the Company may terminate the employment relationship at any time, with or without cause and with or without notice. Likewise, the Company will respect my right to terminate my employment at any time, with or without cause and with or without notice. I further understand that any prior representation, whether expressed or implied to the contrary is hereby superseded and that no promise or representation contrary to the foregoing is binding on the Company unless made in writing and signed by the Company’s president.

Testing Authorization - If offered a position with the Company, I hereby agree to any legally permitted physical, psychological, skill, drug or medical test required by the Company as a condition of employment.

Investigation Authorization - I authorize investigation into all statements and references contained in this application. Said investigation may include credit, driving, criminal background, reference and other background checks. By applying for this job, I also authorize post-hire investigation into my credit, driving and criminal background.

Company Obligation - I understand and agree that the Company’s acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the company has agreed to hire me. I understand that the company is under no obligation to hire me as the result of accepting this completed application.

Submit Resume Here (optional)

Attach Resume

Disclaimer

Applicant understands that this is an Equal Opportunity Employer and committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered. Please complete each section EVEN IF you decide to attach a resume. I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated.

Date

Signature *

Clear