Employment Application
 
 

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 Resource Department.


Date of Application 
Applicant Information  (Required fields are highlighted)
Position(s) applied for first choice
 second choice
 third choice

First Name
Last Name
Social Security #
Street Address

City
State 
Zip
Home #
Mobile #
Other #
Email
Referral Source
(how did you hear of us)
Date available to work
Desired Salary Range
Type of employment desiredFull-TimePart-TimeTemporary
SeasonalOther
 If other, please specify 
Are you 18 or over or,
if under 18, can you furnish a work permit?
YesNo
If no, please explain
Are you a citizen of the United States
YesNo
If no, are you authorized to work in the U.S.
YesNo
Have you ever been employed here before?
YesNo
If yes, give date(s) and position(s)
Have you ever pled "guilty", "no contest" to, or been convicted of a crime?
YesNo
If yes, please provide date(s) and details
Educational Background
Starting with your most recent school attended, provide the following information (up to three).
School (Including City + State) Years
Completed
Completed GPA Major
Diploma GED
Degree 
Certif. 
Other 


Minor:
References
List name and telephone Number of up to three business/work references who are not related to you. If not applicable, list three school or personal references who are not related to you.
Name Title Relationship Telephone Years Known
 
Employment History
Starting with your most recent employer, provide the following information (up to three).
Employer
Telephone
Dates Employed
 Mo/Yr  to Mo/Yr 
  Street Address
Compensation (Starting)
HourlySalary $ per 
Starting job title/final job title
Commission/Bonus/Other Compensation. $
Compensation (Final)
Immediate supervisor and title (most recent position)
May we contact for reference?
YesNoLater
HourlySalary $ per 
Commission/Bonus/Other Compensation $
Why did you leave?
Summarize the type of work performed and job responsibilities

Attachments Demographic Information
The state makes us track this info; we really don't care.

Gender: 

Race: 
Applicant Statement

(You must scroll to the bottom of this section and agree to the terms before submitting your application.)

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

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 may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all others 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 local, state or 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 for me 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 with or without prior notices, 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 this 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 authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

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) eliminate me from further consideration for employment, or (II) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT AGREE UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I agree that by checking the below box, I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

I Agree



  



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