Job Application

Application For Employment

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

Position(s) applied for:*

Date of application:*

Name*

First

Last

Social Security Number:*

Address*

Street Address Street Address Line 2 City State Zip Code

Phone*

Mobile Phone*

Email*

Referral Source (How did you hear about us?)*

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

Yes

If no, please explain:

Have you ever been employed here before?*

Yes

If yes, give dates and positions:

Are you legally eligible for employment in this country?*

Yes

Date available for work:*

What is your desired salary range?*

Type of employment desired:

Full-Time

Part-Time

Temporary

Seasonal

Educational Co-Op

Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law. *

Yes

Need more information about the job's 'essential' functions' to respond

Driver's license number and State (required if driving may be required in the job for which you are applying):

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Employment History
Starting with your most recent employer, provide the following information.

Employer 1 Name:

Employer 1 Phone:

Employer 1 Address:

Street Address Street Address Line 2 City State Zip Code

Employer 1 Starting Job Title:

Employer 1 Ending Job Title:

Employer 1 Immediate Supervisor And Title:

May we contact employer 1 for a reference?

Yes

Later

Why did you leave employer 1?

Summarize the type of work performed at employer 1:

Employer 1 Dates Of Employment:

Employer 1 Compensation:

Hourly

Salary

Employer 1 Compensation (include any bonus or commission) For hourly enter the hourly rate:

Employer 2 Name:

Employer 2 Phone:

Employer 2 Address:

Street Address Street Address Line 2 City State Zip Code

Employer 2 Starting Job Title:

Employer 2 Ending Job Title:

Employer 2 Immediate Supervisor And Title:

May we contact employer 2 for a reference?

Yes

Later

Why did you leave employer 2?

Summarize the type of work performed at employer 2:

Employer 2 Dates Of Employment:

Employer 2 Compensation:

Hourly

Salary

Employer 2 Compensation (include any bonus or commission) For hourly enter the hourly rate:

Employer 3 Name:

Employer 3 Phone:

Employer 3 Address:

Street Address Street Address Line 2 City State Zip Code

Employer 3 Starting Job Title:

Employer 3 Ending Job Title:

Employer 3 Immediate Supervisor And Title:

May we contact employer 3 for a reference?

Yes

Later

Why did you leave employer 3?

Summarize the type of work performed at employer 3:

Employer 3 Dates Of Employment:

Employer 3 Compensation:

Hourly

Salary

Employer 3 Compensation (include any bonus or commission) For hourly enter the hourly rate:

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Skills And Qualifications
Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying:

Computer Skills:

Word Processing

Spreadsheet

Presentation

Internet

Other

Tell us about your expetise with your selections above:

Educational Background

Starting with your most recent school attended, provide the following information.

School (include city and state) 1

Years Completed 1 (ex. 4 years for high school) :

Completed 1:

Diploma

Degree

Certification

GED

Other

GPA 1:

Major/Minor 1:

School (include city and state) (2)

Years Completed (ex. 4 years for high school) :(2)

Completed:(2)

Diploma

Degree

Certification

GED

Other

GPA:(2)

Major/Minor:(2)

School (include city and state)(3):

Years Completed (ex. 4 years for high school) :(3)

Completed:(3)

Diploma

Degree

Certification

GED

Other

GPA:(3)

Major/Minor:(3)

References
List name and telephone number of three business/work reference s 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.

Reference Name (1):

Reference Title (1):

Reference Phone (1):

Number Of Years Known (1):

Reference Name (2):

Reference Title (2):

Reference Phone (2):

Number Of Years Known (2):

Reference Name (3):

Reference Title (3):

Reference Phone (3):

Number Of Years Known (3):

Applicant Statement
l certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.
l expressly authorize, with out 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 any and all rights and claims l may have regarding the employer, its agents, employee s or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.
I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable loca l, state or federal law.
l 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 for me to reapply and fill out a new application.
If l am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.
I also understand if I am hired , I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an l- 9 Form in this regard.
This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status. The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete ormisrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment ,or (ii) may result in my immediate discharge from the employer's service,when ever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. Use your finger or mouse to sign.*

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