Position Applied For

Date of Application

Name 

Street Address

City

State

Zip Code

Main Phone Number

Alternate Phone Number

Email

Name of Employer

Supervisor

May we contact?

YESNO

Street Address

Phone Number

Dates Employed (Month/Year)

From

To

Job Title and Duties

Reason for Leaving

Name of Employer

Supervisor

May we contact?

YESNO

Street Address

Phone Number

Dates Employed (Month/Year)

From

To

Job Title and Duties

Reason for Leaving

Name of Employer

Supervisor

May we contact?

YESNO

Street Address

Phone Number

Dates Employed (Month/Year)

From

To

Job Title and Duties

Reason for Leaving

Have you ever been involuntarily terminated or asked to resign from any job?

YESNO

If yes, please explain

Please explain any gaps in your employment history:

Please list any other experience, job related skills, additional languages, or other qualifications that you believe should be considered in evaluating your qualifications for employment. 

School Name

Year Completed

Diploma/Degree (Yes/No)

Area of Study/Major

Specialized Training

High School

College/University

Graduate School

Trade School

Other

Name and Title

Relationship

Phone Number or Email

Name

Relationship and Years Aquainted

Phone Number or Email

1.

Have you ever used another name?

YESNO

2.

Is any additional information relative to name changes, use of an assumed name, or nickname necessary to enable a check on your work and educational record?

YESNO

a.

If yes to either of the above, please explain:

3.

Have you ever worked for this company before?

YESNO

a.

If yes, please give dates and position:

4.

Do you have friends and/or relatives working for this company?

YESNO

a.

If yes, names and relationships:

5.

On what date are you available to begin work?

6.

Days/Hours available to work:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

7.

Are you available to work? 

FulltimeParttimeShift WorkTemporary

8.

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

YESNO

9.

Can you travel if the position requires it?

YESNO

10.

Can you relocate if the position requires it?

YESNO

11.

Are you at least 18 years old?

YESNO

a.

Note: If under 18, hire is subject to verification that you are of minimum legal age.

12.

If hired, can you present evidence of your identity and legal right to work in this country?

YESNO

13.

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

YESNO

a.

Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for qualified applicants/employees to perform essential job functions.

I hereby authorize the Company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the prior employers and references I have listed to disclose to the Company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby 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 investigation or disclosure. 

In the event of my employment with the Company, I understand that I am required to comply with all rules and regulations of the Company. 

If hired, I understand and agree that my employment with the Company is at-will, and that neither I, nor the Company is required to continue the employment relationship for any specific term. I further understand that the Company or I may terminate the employment relationship at any time, with or without cause, and with or without notice. I understand that the at-will status of my employment cannot be amended, modified, or altered in any way by any oral modifications.

I understand that safety of employees is extremely important to the Company and that the Company is committed to ensuring a safe working environment. I understand that I, and every employee, have a responsibility to prevent accidents and injuries by observing all safety procedures and guidelines and following the directions of my site supervisor. I understand and agree to comply with federal, state, and local regulations related to on-the-job safety and health

I hereby certify that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I understand that if I am selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard.

I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed and the remainder of this Agreement shall be enforceable. 

Name

Date