Employment Application

Applicant Information

Full Name: / Birth Date:
Last / First / M.I.
Address:
Street Address / Apartment/Unit #
City / State / ZIP Code
Phone: / ( ) / E-mail Address:
Date Available: / Social Security No.: / Desired Salary: / $
Position Applied for:
Are you able to provide proof that you are authorized to work in the United States? / YES / NO
Have you ever worked for this company? / YES / NO / If so, when?
Have you ever been convicted of a felony or misdemeanor involving any violent act, use or use or possession of a weapon or act of dishonesty for which the record has not been sealed or expunged? / YES / NO
If yes, explain:

Education

High School: / City/State:
College: / City/State:
Did you graduate? / YES / NO / Degree:
Other: / City/State:
Did you graduate? / YES / NO / Degree:

References

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:
Company: / Phone: / ( )
Address: / Supervisor:
Job Title: / Starting Salary: / $ / Ending Salary: / $
Responsibilities:
From: / To: / Reason for Leaving:
Company: / Phone: / ( )
Address: / Supervisor:
Job Title: / Starting Salary: / $ / Ending Salary: / $
Responsibilities:
From: / To: / Reason for Leaving:

Military Service

Branch:
Rank at Discharge:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that by giving false or misleading information in my application or interview, my application may be rejected and if I am employed, my employment may be terminated at any time. RJA is an equal opportunity employer and complies with all federal and state laws and regulations.
In consideration of my employment, I agree to conform to all company policies and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option.
Signature: / Date:

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Rev 3/1/07