Employment Application

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:----------------------------------------------------------------------------------------------------------
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Telephone #: ---------------------------------------- Email address: ---------------------------------
Social Security #: ------------------------------------------
Type of employment desired:

----------------- full-time ------------------ part-time ---------------- temporary

Date available to start work: ---------------------------------

Are you able to meet the attendance requirements?	Yes	No
Do you have any objection to working overtime if necessary?	Yes	No
Can you travel if required?	Yes	No
Have you ever been previously employed by our organization?	Yes	No
Can you submit proof of legal employment authorization and identity?	Yes	No
If you are under 18, can you furnish a work permit if it is required?	Yes	No
Have you ever been convicted of a crime in the last 7 years?	Yes	No

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?-------------------------------------------------------------------------
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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: --------------------------------------------------------------------
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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):
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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: -----------------------