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Employment Application

* - Indicates required field

Applicant Information

Driver's license number required if driving may be required in the job for which you are applying

Employment Questions

If you are under 18 and it is required, can you furnish a work permit?
Have you ever been employed here before?
Is this application a request for reemployment following an extended military leave of absence from this company?

If yes, additional information may be requested.

Are you legally eligible for employment in this country?
$
Type of employment desired
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.

Have you ever pleaded "guilty" or "no contest" to, or been convicted of, a crime?

Answering "Yes" to either part of this question 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.

Employment History

Starting with your most recent employer, provide the following information:

Most Recent Employer

May we contact for reference?
Starting Compensation
$
Hourly or Salary?
$
Final Compensation
$
Hourly or Salary?
$

Add Another Employer

May we contact for reference?
Starting Compensation
$
Hourly or Salary?
$
Final Compensation
$
Hourly or Salary
$

Add Another Employer

May we contact for reference?
Starting Compensation
$
Hourly or Salary
$
Final Compensation
$
Hourly or Salary?
$

Skills and Qualifications

Computer Skills

Word Processing
Spreadsheet
Presentation
E-mail
Internet
Other

Educational Background

Start with your most recent school attended, provide the following information:

Most Recent School Attended

Completed

Add Another School

Completed

Add Another School

Completed

References

List names and telephone numbers of three business/work references 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.

1st Reference
2nd Reference
3rd Reference

Applicant Statement

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 education 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 representative, 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 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 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 of 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 that 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 the federal immigration laws require me to complete an I-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, 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 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.

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