Employment Application
Applicant Information
Applicant’s name
*
Address
*
City
*
State
*
Zip
*
Home phone
*
Business phone
*
Email
*
Employment Positions
Position(s) Applying for
Date available to begin employment
Salary desired
Are you applying for
Full-Time
Part-Time
PRN
What days and hours are you available for work?
Can you work on the weekends?
Yes
No
Can you work evenings?
Yes
No
Are you available to work overtime?
Yes
No
Personal Information
How were you referred to us?
*
If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?
*
Yes
No
If hired, are you willing to submit to and pass a controlled substance test?
*
Yes
No
Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation?
*
Yes
No
Please describe the functions that cannot be performed
Education, Training and Experience
High School name
Address
City
State
Zip
No. of years completed
Did you graduate?
Yes
No
Degree/diploma earned
College/University name
Address
City
State
Zip
No. of years completed
Did you graduate?
Yes
No
Degree/diploma earned
Technical/Business School name
Address
City
State
Zip
No. of years completed
Did you graduate?
Yes
No
Degree/diploma earned
Military Service: Branch
Rank in Military
Total years of service
Skills/duties
Employment History
May we contact your current employer?
Yes
No
May we run an employment check on other employers listed below?
Yes
No
Even if you have attached a resume,
please describe past and present employment positions below, dating back five years. Please account for all periods of unemployment.
Name of employer
Address
City
State
Zip
Phone
Supervisor
Position and duties
Reason for leaving
Length of employment (include dates)
May we contact this employer for references?
Yes
No
Add another employer?
Name of employer
Address
City
State
Zip
Phone
Supervisor
Position and duties
Reason for leaving
Length of employment (include dates)
May we contact this employer for references?
Yes
No
Add another employer?
Name of employer
Address
City
State
Zip
Phone
Supervisor
Position and duties
Reason for leaving
Length of employment (include dates)
May we contact this employer for references?
Yes
No
Add another employer?
Name of employer
Address
City
State
Zip
Phone
Supervisor
Position and duties
Reason for leaving
Length of employment (include dates)
May we contact this employer for references?
Yes
No
Add another employer?
Name of employer
Address
City
State
Zip
Phone
Supervisor
Position and duties
Reason for leaving
Length of employment (include dates)
May we contact this employer for references?
Yes
No
References
List below three persons who have knowledge of your work performance within the last four years. Please include professional references only.
Name
Address
City
State
Zip
Phone
Occupation
No. of years acquainted
Name
Address
City
State
Zip
Phone
Occupation
No. of years acquainted
Name
Address
City
State
Zip
Phone
Occupation
No. of years acquainted
Please Read and Initial Each Paragraph, then Sign Below
I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure can be grounds for rejection of application or, if I am employed by this company, terms for my immediate expulsion from the company.
I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by the company.
I permit the company to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.
Signature of Applicant
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date