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:
StreetCity 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 No
If no, please explain:
Have you ever been employed here before? If yes, give dates and positions:
Are you legally elible for employment in this country?........................................................................................................ Yes No
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)?
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 pleaded "guilty" or "no contest" to, or been convicted of a crime?........................................................ Yes No
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:
to
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:
to
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:
to
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 MajorMinor
DiplomaGED
DegreeCert
Other:
DiplomaGED
DegreeCert
Other:
DiplomaGED
DegreeCert
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 NameRelationship to youCompanyTitleTelephone 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 this 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 instituions 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 any basis prohibited by applicable local, state or federal law.
I understand that this application remain 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 for me 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 mployer is authorized to make any assurances to the contrary and that no implied oral or wirtten 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 authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.
This Company does not tolerate unlawful discrimination in its employment pratices. No question on this application is used fo rthe purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, cizienship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status. The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and throughly.
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 that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
SignatureIP Address:Date: