Application for Employment


 
                                                                                    Date of Application _______________
Name:
_______________________________________________________________
   (Last)                                       (First)                                      (Middle)
Address:
______________________________________________________________
   (Street)                                       (City)                                      (State)      (Zip)
Telephone:
_________________
Position(s)
Applied for:		 Who referred
you to us:
____________________ ____________________
Are you over 18 years of age? Yes No
Have you ever been employed here before? Yes No
Are you legally eligible for employment in this country? Yes No
(Proof of U.S. citizenship or immigration status will be required upon employment)
Date available for work: ___/___/___
Type of employment desired:         Full Time         Part Time         Temporary
Are you able to meet the attendance requirements of the position? Yes No
Have you been convicted of a felony in the last seven(7) years? Yes No
(Such conviction may be relative if job related, but does not bar you from employment)
If Yes, please explain:_________________________________________

Employment Experience
List your last four (4) employers, assignments or volunteer activities, starting with the most recent.

Employer Supervisor Employed Rate/Salary
From To From To
Address Reason for leaving        
Job Title Work Performed
Employer Supervisor Employed Rate/Salary
From To From To
Address Reason for leaving        
Job Title Work Performed
Employer Supervisor Employed Rate/Salary
From To From To
Address Reason for leaving        
Job Title Work Performed
Employer Supervisor Employed Rate/Salary
From To From To
Address Reason for leaving        
Job Title Work Performed

Military Service Record

Armed Forces Service: Yes No                        From: _______________ To: _____________
Branch of Service: ________________________   Duties: ______________________________ Rating at time of Discharge: ______________________________________________________

Education

School Date Name of School City/State Course Did You Graduate
From To
Grammar            
High            
College            
Other            

Special skills and Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.

___________________________________________________________________

References
Give name, address, and telephone number of three references who are not related to you, and are not previous employers.

Name Address, City, State Occupation Telephone
       
       
       
I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in the application for employment as may be necessary in arriving at an employment as may be necessary in arriving at an employment decision.

I will be required to successfully pass a drug screening test before beginning the job assignment.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or with out cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

________________________________________   ________________
Signature of Applicant                                        Date