COMPLETE ALL QUESTIONS TRUTHFULLY AND ACCURATELY.
INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.
Date: Full Time Part Time
Position Desired: Location applying for:
PERSONAL DATA
Name:
Social Security #:
 
Present Address
City:
How long have you lived there?
 
Previous Address
City:
How long did you live there?


Telephone #: Cell #:
Email Address:
 
Do you have a legal right to work in the United States? Yes No
(You will be required to show proof of citizenship)
 
Have you ever worked for this Company before? Yes No
If Yes, please give dates and position:
 
Have you ever applied for a position with this Company before: Yes No
If Yes, when?
 
How did you learn about this company?
Newspaper advertisement Employee Walk-in Other
 
Do you have any friends or relatives working here? Yes No
If Yes, who?
 
Date available for work:
Can you work the following? Check all that apply.
Saturday Sunday Weekdays Holidays Day Evening Late Night Overtime
 
Starting wage expected: hourly salary
 
Have you ever pled guilty or "no contest" to a felony or been convicted of a felony? Yes No
If "YES", please give date and details of each:
NOTE: Answering "YES" to this question does not constitute an automatic bar to employment. Only those crimes which are substantially related to the position you are seeking will be considered.
RECORD OF PREVIOUS EMPLOYMENT
Please list the names of your present or previous employers in chronological order with present or last employer listed first. Be sure to account for all periods of time including military service and any period of unemployment. If self-employed, give firm name and supply business references. Please attach resume (if any).
Dates Worked: From To
Salary: Starting Final
Employer's Name
Your Job Title and Dates
Employer's Street Address
City Zip
Supervisor's Name
Supervisor's Title
Supervisor's Telephone #:
Reason for Leaving
May this employer be contacted at this time for a reference? Yes No
 
Dates Worked: From To
Salary: Starting Final
Employer's Name
Your Job Title and Dates
Employer's Street Address
City Zip
Supervisor's Name
Supervisor's Title
Supervisor's Telephone #:
Reason for Leaving
May this employer be contacted at this time for a reference? Yes No
 
EDUCATION
  School Name Years Completed Diploma/Degree Course of Study or Major Specialized Training, Experience, Skills, & Extra-Curricular Activities
High School
College/University
Trade or Correspondence
Other School
Only fill in this area if you are applying for a job that is clerical in nature or unless you have been instructed to do so.
RELEVANT SKILLS
Computers: List software packages with which you have experience
Can you operate a 10-key calculator by touch? Yes No
How fast can you type? words per minute
Relevant courses you are taking now:
Relevant course you expect to take:
EMERGENCY INFORMATION
In case of an accident or other emergency, who should we contact?
Name: Relationship:
Home Address:
City
Telephone
 
Work Address:
City
Telephone
 
BUSINESS REFERENCES
You must list three former or current business references. Please do not list personal references.
NameOccupationAddressTelephone Number# Years Known
APPLICANT'S STATEMENT
I understand that use of this form does not indicate that there are positions open and does not in any way obligate this Company. If employed, I agree to abide by and observe all Company rules and regulations. I understand that any such future employment is terminable by either party at will with or without notice or cause and that any false or misleading information or omission on the application shall be sufficient cause for rejection or immediate dismissal. I further understand that no person other than the President of the Company has the authority to enter into any agreement for employment for any specified period of time or to modify or amend the provisions stated herein. I understand that I must submit to a drug test as part of the application process and that this Company reserves the right to require me to submit to a drug test at any time and also reserves the right to require me to submit to an alcohol test and/or medical examination to the extent permitted by law. I authorize the Company to investigate my background, including any criminal record. I further understand that the Company may contact my previous employers and I authorize those employers to disclose to the Company all records and other information pertinent to my employment with them and I release them and their business from any liability whatsoever. I also authorize the Company to provide truthful information concerning my employment with it to my future prospective employers and I agree to hold it harmless for providing such information. I understand that this application will only be considered active for 30 days. I understand that if I wish to receive consideration for employment after that time, I must reapply. I certify that all of the information that I provide on this application and in any interview will be true and accurate. I understand that if I am employed and any such information is later found to be false or misleading in any respect, I may be discharged.
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THIS STATEMENT. *Typing Your Name Below Constitutes a Signature.
 
Signature of Applicant Date
 
 
This Company is an Equal Opportunity Employer. All applications are considered for employment without regard to race, color, sex, age, disability, religion, national origin, or military veteran status.