PERSONAL

Date of Application

Position Applying For

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Type of employment desired:

Date Available for Work:

What is your desired wage?

Referral Source (How did you hear about us?)

Have you ever been employed here before?

Yes
No

Give dates and positions

List any friends or relatives working for us

Driver’s License number if driving may be required in position for which you are applying

Are you below the age of 18?

Yes
No

Are you legally authorized to work in the United States?

Yes
No

Have you ever pled “guilty” or “no-contest” to, or been convicted of a crime?

Yes
No

Please explain

Employment History

Starting with your most recent employer, provide the following information.

Employer

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Starting Job Title/Final Job Title

Why did you leave?

Immediate Supervisor and Title

May we contact for reference?

Yes
No
Later

Dates Employed

Compensation

Summarize type of work performed and job responsibilities

What did you like most about your position?

What were things you liked least about the position?

Employer

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Starting Job Title/Final Job Title

Why did you leave?

Immediate Supervisor and Title

May we contact for reference?

Yes
No
Later

Dates Employed

Compensation

Summarize type of work performed and job responsibilities

What did you like most about your position?

What were things you liked least about the position?

Skills and Qualifications

Summarize any special training skills, licenses and/or certificates that may assist you in performing the position for which you are applying.

Educational Background

Starting with your most recent school attended, provide the following information.

School (include City & State)

Years Completed

Completed

GPA

Major/Minor

School (include City & State)

Years Completed

Completed

GPA

Major/Minor

School (include City & State)

Years Completed

Completed

GPA

Major/Minor

REFERENCES

List the name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

Name *

First

Last

Title

Relationship to You

Phone

Years Known

Name *

First

Last

Title

Relationship to You

Phone

Years Known

Name *

First

Last

Title

Relationship to You

Phone

Years Known

Applicant Statement *

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president. I also understand that if I am hired, I will be required to provide proof of 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 any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.