Employment Application

An Equal Opportunity Employer
We do not discriminate on the bases of race, color, religion, national origin, gender, sexual orientation, age, or disability. It is our intention that all qualified applicants will be given equal opportunity and that selections decisions be based on job-related factors.

Each question is to he answered fully and accurately. No action can be taken on the application until all questions have been answered.

Position Applied for Today's Date

Seeking:               Shifts: AM PM

Possible Start Date

Last Name First Name Middle Initial

Present Street Address State Zip

Are you 18 years of age, or older?     (If hired you may he remind to submit proof of age)

Phone Number

If hired, can you submit proof you are eligible to work in the US?  

Are you a citizen of the United States?  

If no, are you authorized to work in the U.S.?  

Have you ever worked for this company?  

If yes, when and where?

Have you ever been convicted of a felony?  

If yes, explain: ("Yes" does not automatically disqualify you from employment. because the nature of the offense, date, and position for which you are applying will also he considered)

 

Please list three professional references

Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:

 

Previous Employment

Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?  
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?  
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?  

 

Please Read Each Statement Carefully Before Signing

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I authorize and agree to cooperate in a thorough investigation of all statements made herein and other matters relating to my background and qualifications. I understand that any investigation conducted may include a request for employment and educational background, credit reports, consumer reports, driving record, and criminal history. I authorize any person, school, current, and former employer, consumer reporting agency, and any other organizations or agency to provide information relevant to such investigation and I hereby release all persons and corporations requesting or supplying information pursuant to such investigation from all liability or responsibility to me for doing so. I understand that I have the right to make a written request within a reasonable period of time for complete disclosure of the nature and scope of any investigation. I further authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the job for which I am being considered or any future job in the event that I am hired. I understand that I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post -employment drug screen as a condition of being hired or of my continued employment, if required.

 

I have read, understand, and by my signature consent to these statements.

 

Signature:
Date:

 

 

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