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We
are an equal opportunity employer and do not unlawfully discriminate in
employment. No question on this application is used for the purpose of
limiting or excluding any applicant from consideration for employment
on a basis prohibited by local, state, or federal law. Equal access to
employment, services, and programs is available to all persons. Those
applicants requiring reasonable accommodation to the application and/or
interview process should notify a representative of the organization.
Applicant name: --------------------------------------------------------------------------------------------
Date:---------------------------------------------------
Position(s) applied for or type of work desired:-----------------------------------------------------------------------------------------------------------
Address:----------------------------------------------------------------------------------------------------------------------------------------------------------------------
Telephone #: ----------------------------------------------------- Email
address: --------------------------------------------------------------------------------
Social Security #: ----------------------------------------------
Type of employment desired: ----------------- full-time ------------------
part-time ---------------- temporary
Date available to start work: ----------------------------------------------------
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Are you able
to meet the attendance requirements?
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Yes
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No
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Do you have
any objection to working overtime if necessary?
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Yes
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No
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Can you travel
if required?
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Yes
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No
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| Have
you ever been previously employed by our organization? |
Yes
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No
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| Can
you submit proof of legal employment authorization and identity? |
Yes
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No
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| If
you are under 18, can you furnish a work permit if it is required? |
Yes
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No
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| Have
you ever been convicted of a crime in the last 7 years? |
Yes
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No
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If yes, please explain
(a conviction will not automatically bar employment): -----------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Drivers license number (if driving is an essential job duty): ---------------------------------------------------------------------------------------
How were you referred to us?-------------------------------------------------------------------------------------------------------------------------------------
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:-----------------------------------------------------------------------------------------------------------------------------------------------------
Other Skills and Qualifications
Summarize
any job-related training, skills, licenses, certificates, and/or other
qualifications and awards:
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Educational History
List school name and location, years completed, course of study, and any
degrees earned:
High school: ---------------------------------------------------------------------------------------------------------------------------------------------------------------
College: ---------------------------------------------------------------------------------------------------------------------------------------------------------------------
Professional Training:-------------------------------------------------------------------------------------------------------------------------------------------------
Other:--------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Personal References
List
3 references names, telephone numbers, and years known (do not include
relatives or employers):
I hereby authorize
the potential employer to contact, obtain, and verify the accuracy of
information from all previous employers, educational institutions, and
references contained in this application. I also hereby release from liability
the potential employer and its representatives for seeking, gathering,
and using such information to make employment decisions and all other
persons or organizations for providing such information.
I understand that
any misrepresentation or material omission made by me on this application
will be sufficient cause for cancellation of this application or immediate
termination of employment if I am employed, whenever it may be discovered.
If I am employed,
I acknowledge that there is no specified length of employment and that
this application does not constitute an agreement or contract for employment.
Accordingly, either I or the employer can terminate the relationship at
will, with or without cause, at any time, so long as there is no violation
of applicable federal or state law.
I understand that
it is the policy of this organization not to refuse to hire or otherwise
discriminate against a qualified individual with a disability because
of that persons need for a reasonable accommodation as required by the
ADA.
I
also understand that if I am employed, I will be required to provide satisfactory
proof of identity and legal work authorization within three days of being
hired. Failure to submit such proof within the required time shall result
in immediate termination of employment.
I represent and
warrant that I have read and fully understand the foregoing, and that
I seek employment under these conditions.
Applicant signature: --------------------------------------------------------------------------------------------
Date: ---------------------------------------------
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