EMPLOYMENT APPLICATION
Please read the following carefully before completing the application form.
  • To be considered for employment, it is important that all portions of this application be completed. Please do not use the phrase "see resume" to substitute for completeness of this form.
  • Our intent is to recruit, hire, train and promote all persons in all job groups in accordance with law, without regard to race, color, religion, marital status, disability, national origin, or any other protected status.
  • We maintain a smoke free work place. There is no smoking in our building.
  • Our hiring process might require each applicant to undergo a drug and alcohol screening examination.
  • This application will be maintained on active status for a period of 30 days.
PERSONAL INFORMATION
Name
Last
 First
Middle
Telephone Number
 Email
 Have you previously worked or applied here?

Yes - If Yes, what dates?
No
Social Security Number

To be provided		 Today's Date
Date Available
 Position Applied For
 Full Time
Part Time
Present Street Address
 City
 Zip
 State
Former Address
 City
 Zip
 State
Message/Emergency Contact
 Telephone
 Names of relatives/friends employed here
Expected Salary
 Are you 16 or older?
Yes
No		 Based on what you have been told or read, is there
any reason that you cannot do the essential functions
of this job?
PERSONAL REFERENCES
Please list three individuals who have knowledge of your abilities and character. Do not list former employees or relatives.
Name
 How Long Known?
 Home Telephone
 Work Telephone
Other names under which you are known to personal or employment references you have listed on this application.
EDUCATION
Please list last High School, and all businesses and Trade Schools, as well as Colleges attended.
Name and location of School Courses of study GPA Did you graduate
Yes
No
Yes
No
Yes
No
Yes
No
Extracurricular activities and other educationally related information you feel we should know.
SPECIAL SKILLS
Summarize special skills and qualifications acquired from education, employment or other experience.
EMPLOYMENT HISTORY
Please list ALL of your former employers within the last 10 years. Begin with the most recent to present.
MAY WE CONTACT YOUR PRESENT EMPLOYER?
Yes
No - If no, please explain.
1 Most Recent
From
Mo. Yr.
 To
Mo. Yr.
 Name and location of Employer
Name

Location
 Nature of Business
 Your position
 Ending Salary
 Reason for leaving
 Name & Business Phone of Last Immediate Supervisor
Name

Phone
2
From
Mo. Yr.
 To
Mo. Yr.
Name and location of Employer
Name

Location
Nature of Business
 Your position
 Ending Salary
 Reason for leaving
 Name & Business Phone of Last Immediate Supervisor
Name

Phone
3
From
Mo. Yr.
 To
Mo. Yr.
Name and location of Employer
Name

Location
Nature of Business
 Your position
 Ending Salary
 Reason for leaving
 Name & Business Phone of Last Immediate Supervisor
Name

Phone
4
From
Mo. Yr.
 To
Mo. Yr.
Name and location of Employer
Name

Location
Nature of Business
 Your position
 Ending Salary
 Reason for leaving
 Name & Business Phone of Last Immediate Supervisor
Name

Phone
5
From
Mo. Yr.
 To
Mo. Yr.
Name and location of Employer
Name

Location
Nature of Business
 Your position
 Ending Salary
 Reason for leaving
 Name & Business Phone of Last Immediate Supervisor
Name

Phone
  • Does your present employer know you are considering leaving? Yes No
  • Are there any previous employers that might not rehire you? Yes No
    Please explain if Yes
  • Do you have commitments to another employer that might affect your work with us? Yes No
    Please explain if Yes
  • In the past two years, how many scheduled days of work have you missed?
    Is this typical for you? Yes No
ADDITIONAL INFORMATION
MILITARY RECORD
U.S. Military Service
From

To
Branch
 Rank on Discharge
Reason for leaving Service
 Duties
CRIMINAL RECORD
Note - a conviction record will not necessarily bar you from employment.
Within the past 7 years, have you been convicted of an offense against civil or military law, or been released from a prison or other detention facility? Omit 1. Traffic violations with a fine under $100.00 except where liquor or drugs were involved and 2. Any offense committed before you 21st birthday which was finally adjudicated in a juvenile court or under a youth offender law.
Yes No
If Yes , please indicate the nature of the offense, date, court and disposition.
VISA INFORMATION
Are you legally authorized/permitted to work in the United States? Yes No
AGREEMENT
Please read the following statements carefully.
I hereby affirm that the information provided on this application for (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.

I understand that my employment can be terminated, with or without cause, at any time at the discretion of either the company or myself. I understand that no management official other than the CEO has the authority to enter into any agreement contrary to the foregoing or make any oral assurance or promise of continued employment.

I authorize persons, schools, my current employer (if applicable), and previous employers and organizations named in this application (and Accompanying resume, if any) to provide any relevant information that may be required to arrive at an employment decision. I release all parties from liability for any damages that may result from furnishing same to your organization.

I agree
Yes No
Name

Date
Please copy and paste your resume in the text field below.