Application for Employment

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

Date of application:

MM slash DD slash YYYY

Position(s) applied for:

Select Referral Source:

Name of Source:

If you would like to refer to someone as your referral source please add the name of your source in this field.

Contact Details

Name(Required)

First Middle Last

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone:(Required)

Email:(Required)

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

Yes

N/A

If no, please explain:

Have you applied before?(Required)

Yes

Add date(s) when you applied

MM slash DD slash YYYY

Position applied for?

Add date(s) when you applied

MM slash DD slash YYYY

Position applied for?

Add date(s) when you applied

MM slash DD slash YYYY

Position applied for?

Have you ever been employed here before?(Required)

Yes

From:

MM slash DD slash YYYY

To:

MM slash DD slash YYYY

From:

MM slash DD slash YYYY

To:

MM slash DD slash YYYY

Are you legally eligible for employment in this country?(Required)

Yes

Date available for work:(Required)

MM slash DD slash YYYY

What is your desired salary range?

Select Type of employment desired:(Required)

Will you relocate if job requires it?(Required)

Yes

Will you travel if job requires it?(Required)

Yes

Are you able to meet the attendance requirements of the position?(Required)

Yes

Will you work overtime if required?(Required)

Yes

If no, please explain:

Have you ever been bonded?(Required)

Yes

Have you ever pled “guilty” if “no contest” to, or been convicted of a crime?(Required)

Answering “Yes” to this question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applying for will be considered.

Yes

Driver’s license number if driving is an essential job function:

Please select the State where your license was issued:

Employment History

Provide the following information of your past and current employers, assignments or volunteer activities, starting with the most recent (use additional sheets if necessary). Explain any gaps in employment in comment section below

EMPLOYER:

FROM:

MM slash DD slash YYYY

TO:

MM slash DD slash YYYY

SUMMARIZE THE TYPE OF WORK PERFORMED:

STARTING PAY RATE:

ENDING PAY RATE:

STARTING JOB TITLE:

FINAL TITLE:

REASON FOR LEAVING:

EMPLOYER:

FROM:

MM slash DD slash YYYY

TO:

MM slash DD slash YYYY

SUMMARIZE THE TYPE OF WORK PERFORMED:

STARTING PAY RATE:

ENDING PAY RATE:

STARTING JOB TITLE:

FINAL TITLE:

REASON FOR LEAVING:

EMPLOYER:

FROM:

MM slash DD slash YYYY

TO:

MM slash DD slash YYYY

SUMMARIZE THE TYPE OF WORK PERFORMED:

STARTING PAY RATE:

ENDING PAY RATE:

STARTING JOB TITLE:

FINAL TITLE:

REASON FOR LEAVING:

Comments:

Skills and Qualifications

Summarize any special training, skills, licenses, and/or certificates that may qualify you as being able to perform job- related functions in the position for which you are applying.

Skills and Qualifications

Educational Background

List last 3 schools attended, starting with the most recent.

School

Years completed

Degree Diploma or Certificate

School

Years completed

Degree Diploma or Certificate

School

Years completed

Degree Diploma or Certificate

References

List name and telephone number of 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.

Name

Telephone Number

Number Of Years Known

Name

Telephone Number

Number Of Years Known

Name

Telephone Number

Number Of Years Known

Additional Information

List professional, trade, business or civic association and any offices held.

EXCLUDE MEMBERSHIPS THAT WOULD REVEAL RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, CITIZENSHIP, AGE, MENTAL OR PHYSICAL DISABILITIES, VETERAN/RESERVE NATIONAL GUARD OR ANY OTHER SIMILARLY PROTECTED STATUS.

Organization

Office Held

List special accomplishments, publications, awards, etc.

Applicant Statement

I certify that all information I have provided to apply for and secure work with the employer is true, complete, and correct.

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) cancel further consideration of this application, or (ii) immediately discharge me form the employer’s service, whenever it is discovered.

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 institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering ad using such information in the employment process and all other persons, corporations, or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law.

I understand that this application remains 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 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 without prior, and the employer reserves the same right to terminate employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contact for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurance to the contrary and that no implied oral or written agreement contrary to the foregoing express language is 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 authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

Signature of Applicant:

Date:

MM slash DD slash YYYY