Law Office of Curtis O Barnes

Employment Application

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resource Department.

Position(s) applied for:

Date of Application:

Name:

Social Security Number:

Address:
	Street	City	State	Zip Code

Telephone Num:

Mobile/Beeper/Other Num:

E-mail Address:

Referral Source (How did you hear about us?

If you are under 18 and it is required, can you furnish a work permit?...............................................................................

Yes

If no, please explain:

Have you ever been employed here before? If yes, give dates and positions:

If hired can you present evidence of your eligibility to work in the United States?...............................................................

Yes

Date available for work:

What is your desired salary range?

Type of employment desired:

Full-Time

Part-Time

Temporary

Seasonal

Educational Co-Op

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

Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.
Yes	No	Need more information about the job's "essential" functions' to respond

Driver's license number required if driving may be required in the job for which you are applying:

State

Answering "yes" to either of the following questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Have you ever plead guilty or non-contest to or been convicted of a felony or serious misdemeanor. You do not need to reveal convictions for marijuana-related offenses that are more than two years old................................................................

Yes

If yes, please provide date(s) and details:

Employment History

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

Employer:	Telephone:

Street Address:	City:	State:	Zipcode:

Starting job title/final job title:

Immediate supervisor and title (for most recent position held):	May we contact for reference
	Yes No Later

Date Employed:

Compensation (Starting)

Hourly Salary

$ per

Compensation (Final)

Hourly Salary

$ per

Why did you leave?	Commission/Bonus/Other Compensation:
	$

Summarize the type of work performed and job responsibilities.

Employer:	Telephone:

Street Address:	City:	State:	Zipcode:

Starting job title/final job title:

Immediate supervisor and title (for most recent position held):	May we contact for reference
	Yes No Later

Date Employed:

Compensation (Starting)

Hourly Salary

$ per

Compensation (Final)

Hourly Salary

$ per

Why did you leave?	Commission/Bonus/Other Compensation:
	$

Summarize the type of work performed and job responsibilities.

Employer:	Telephone:

Street Address:	City:	State:	Zipcode:

Starting job title/final job title:

Immediate supervisor and title (for most recent position held):	May we contact for reference
	Yes No Later

Date Employed:

Compensation (Starting)

Hourly Salary

$ per

Compensation (Final)

Hourly Salary

$ per

Why did you leave?	Commission/Bonus/Other Compensation:
	$

Summarize the type of work performed and job responsibilities.

Computer Skills (Check appropriate boxes. Include software titles and years of experience.)

Word Processing............................................	Years:	E-Mail..................................................................	Years:
Spreadsheet...................................................	Years:	Internet................................................................	Years:
Presentation...................................................	Years:	Other.....	Years:

Educational Background

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

School

Year

Degree

Major

Minor

	Diploma			GED
	Degree			Cert
	Other:

	Diploma			GED
	Degree			Cert
	Other:

	Diploma			GED
	Degree			Cert
	Other:

References

List 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.

Reference Name	Relationship to you	Company	Title	Telephone Number

Attach Resume

When attaching a resume please ensure that the file name does not contain space and no wild characters like '&' or '@' symbol. Doing so your resume will not be attached.

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with Law Office of Curtis O Barnes (LOCOB) is true, complete and correct. I further certify that I 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 expressly authorize, without reservation, LOCOB, 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 and/or job interview.

I hereby waive any and all rights, claims, liabilities and causes of action, known or unknown, fixed or contingent, I may have regarding LOCOB , any of its successors, its agents, its employees, its officers, its directors or its representatives, for providing or receiving any information regarding my qualifications for employment. This release includes, but is not limited to, claims of defamation, libel, slander, negligence, or interference with contract or profession.

I hereby allow any company, person, or educational institute I listed as a reference on my employment application to disclose any information they may have regarding my qualifications for employment, including but not limited to employment dates, descriptions of jobs performed, salary and wage rates, and personal attributes.

I understand that this application may remain current for only 30 days. At the conclusion of that time, if I have not heard from LOCOB and still wish to be considered for employment, it may be necessary for me to complete a new application.

If I am hired, I understand I am free to resign at any time, with or without cause and with or without prior notice, and LOCOB 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 LOCOB 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 LOCOB's chief executive officer or president.

I understand and acknowledge that all employment with LOCOB is "at-will". This means, if hired, I am free to resign my employment at any time and LOCOB is free to terminate my employment at any time, with or without cause and with or without notice, except where specifically precluded by law. I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between LOCOB and me. In addition, I understand and agree that if I am employed my employment is for no definite or determinable period of time. I understand that no supervisor or representative LOCOB is authorized to make any assurances to the contrary and that no implied oral or written agreement contrary to the foregoing express language are valid unless they are in a writing signed by me and LOCOB's chief executive officer or president.

I understand if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard.

I understand LOCOB 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 any basis prohibited by applicable local, state or federal law.

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.

I certify I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature

IP Address:

Date: