Job Application

Personal Information
Last Name First Name Middle Name Social Security #
Street City State Zip Code
Telephone # Mobile Phone # Email Address Position Applied For
If you are under 18, and it is required, can you furnish a work permit? Yes

No
If No, please explain:
Have you ever been employed here before? Yes

No
If yes give dates and positions
Are you legally eligible for employment in this country? Yes

No
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 meet the attendance requirements of the position? Yes

No
Have you ever pled “guilty” or “no contest” to, or been convicted of a crime? Yes

No
If yes please provide:
Date Details
Answering yes to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.
Drivers license number (if driving is an essential job function) State
Employment History
1
From (Starting Date) To (Ending Date) Employer Telephone #
Job Title Address
Immediate supervisor and Title Summarize the nature of work performed & job responsibilities
May we contact for reference? Reason for leaving
Hourly Rate / Salary
Starting $ Per Final $ Per
2
From (Starting Date) To (Ending Date) Employer Telephone #
Job Title Address
Immediate supervisor and Title Summarize the nature of work performed & job responsibilities
May we contact for reference? Reason for leaving
Hourly Rate / Salary
Starting $ Per Final $ Per
3
From (Starting Date) To (Ending Date) Employer Telephone #
Job Title Address
Immediate supervisor and Title Summarize the nature of work performed & job responsibilities
May we contact for reference? Reason for leaving
Hourly Rate / Salary
Starting $ Per Final $ Per
Summarize any training, skills, licenses, and / or certificates that may be qualify you as being able to perform job-related functions in the position for which you are applying.
Educational Background
High School Number of Years Completed Did you Graduate? Course of Study
Yes

No
College Number of Years Completed Did you Graduate ? Course of Study
Yes

No
Other Number of Years Completed Did you Graduate ? Course of Study
Yes

No
References
Name Telephone # Number of years Known
I certify that all information I have provided in order to apply for and secure work with the employer is true, complete, and correct.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer’s service, whenever it is discovered.

I expressly authorize, without 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 I have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no questions on this application are used for the purpose of limiting or excusing tiny applicant from consideration for employment on a basis prohibited by applicable local, state, and federal law.

I 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 to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, unless otherwise 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 that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an 1-9 Form in this regard.
I certify that I have read, fully understand and accept all terms of the foregoing Application Statement. I agree that the electronic submission of this application acts as my signature for all legal purposes pertaining to this application.
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