APPLICATION FOR EMPLOYMENT

We consider applicants for all positions without regard to race, color, religion, creed, gender, national
origin, age, disability, marital or veteran status, or any other legally protected status.

(PLEASE PRINT)

Position applied for: ______Date:______

How did you learn about us? ______

Applicant Name: ______

Address: ______

Telephone Number(s): ______

Date Available to work:______Desired Salary Range? ______

If you are under 18 years of age, can you provide required proof of your eligibility to work?______

Have you ever applied with us before?______Date:______

Have you ever been employed by us before?______Date:______

Are you currently employed?______

May we contact your present employer?______

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?______(proof of citizenship or immigration status will be required upon employment.)

Are you available to work: Full-time ___ (please indicate 1 2 3 shift)

Part-Time ___ (Mornings Afternoon Evening)

Temporary ___ (Dates available __/__/__ - __/__/__)

Have you been convicted of a felony within the last five years? ______If yes, please explain ______

A criminal record does not constitute an automatic bar to employment and will be considered only as it relates to the job in question.

EMPLOYMENT HISTORY

Please provide all employment information for your past four employers starting with the most recent.

Employer: Position held:

Address: Telephone #:

Immediate supervisor and title:

Dates employed: from to Salary:

Job summary:

Reason for leaving:

Employer: Position held:

Address: Telephone #:

Immediate supervisor and title:

Dates employed: from to Salary:

Job summary:

Reason for leaving:

Employer: Position held:

Address: Telephone #:

Immediate supervisor and title:

Dates employed: from to Salary:

Job summary:

Reason for leaving:

Employer: Position held:

Address: Telephone #:

Immediate supervisor and title:

Dates employed: from to Salary:

Job summary:

Reason for leaving:

Educational History

List school name and location, course of study, years completed, and any degrees earned:

Name and Address / Course of
Study / Years Completed / Diploma
Degree
Elementary
School
High
School
College
Other

Other Skills and Qualifications

Summarize any job-related training, skills, licenses, certificates, and/or other qualifications:

References

List 3 references names, telephone numbers, and years known (do not include relatives or employers):

Name: ______Phone #: ______Years Known: ______

Name: ______Phone #: ______Years Known: ______

Name: ______Phone #: ______Years Known: ______

I certify that the answers given herein are true and correct.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Applicant signature: Date:

January 2007

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