Employment Application

Name *

First

Middle

Last *

Last

Street Address *

City/State/Zip *

Phone Number *

Number

Driver's License OR State ID Number

State

Expiration Date (MM/DD/YYYY) *

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

Yes

No

Are you legally eligible for employment in the United States? *

Yes

No

Are you at least 18 years old? *

Yes

No

In under 18 years of age, can you furnish a work permit?

Yes

No

Have you been convicted of a felony? *

Yes

No

Are you a veteran? *

Yes

No

List any special skills or training:

Employment Information

Are you seeking full-time, part-time, or temporary work? *

Full Time

Part Time

Temporary

What hours and shift(s) would you prefer to work? *

Weekdays

Weekends

Mornings

Evenings

Are you willing to work

Overtime?

Weekends?

Holidays?

Have you ever worked for this organization before? *

Yes

No

Are you currently employed? *

Yes

No

If hired, when would you be able to start? (MM/DD/YYYY) *

Have you ever been discharged or asked to resign from any position? *

Yes

No

If yes, please describe:

List any friends or relatives employed by this company:

Education

Highest Level Achieved: *

Currently Enrolled? *

Yes

No

Name of School *

Location *

Degree or Major (or N/A)

Minor (or N/A)

Work History

Company 1

Company/Organization Name *

Address *

Dates of Employment (MM/DD/YYYY-MM/DD/YYYY) *

Job Title *

Job Duties (briefly describe) *

Specific reason for leaving *

Reference *

Reference Position *

Reference Phone *

May we contact the employer listed above? *

Yes

No

If no, please list a peer or professional reference from this employer that we may contact

Company 2

Company/Organization Name *

Address *

Dates of Employment (MM/DD/YYYY-MM/DD/YYYY) *

Job Title *

Job Duties (briefly describe) *

Specific reason for leaving *

Reference *

Reference Position *

Reference Phone *

May we contact the employer listed above? *

Yes

No

If no, please list a peer or professional reference from this employer that we may contact

Company 3

Company/Organization Name *

Address *

Dates of Employment (MM/DD/YYYY) *

Job Title *

Job Duties (briefly describe) *

Specific reason for leaving *

Reference *

Reference Position *

Reference Phone *

May we contact the employer listed above? *

Yes

No

If no, please list a peer or professional reference from this employer that we may contact

Accomodations & At-Will Employment Agreement

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other legally protected status. If applicable, please refer to the job descriptions provided for the position for which you are applying.

Are you able to perform all these tasks with or without reasonable accomodation? *

Yes

No

Please describe which tasks, if any, you will need accommodation to perform, and explain below what type of accommodation you will need. Please describe:

I certify that I have personally completed this application. I declare that the information provided in this employment application is true and complete and I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification for my dismissal from employment if discovered at a later date. I agree to immediately notify this company if I should be convicted of a crime while my job application is pending or during my employment, if hired.

I understand and agree that nothing contained in this application or conveyed during any interview is intended to create an employment contract between the company and me. In addition, I understand and agree that if you employ me, in consideration of my employment, my employment and compensation will be at-will status and such a charge can only be done in writing. I HAVE READ, UNDERSTAND, AND AGREE TO THE ABOVE

Signature

Clear

Today's Date *

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Employment Application

Employment Information

Education

Work History

Company 1

Company 2

Company 3

Accomodations & At-Will Employment Agreement

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