EMPLOYMENT APPLICATION
Please fill out the entire application.
EMPLOYER INFORMATION
Employer Name: _______________________________________________
Address: _____________________________________________________
City, State, and Zip Code: _______________________________________
Telephone: ____________________
___________________ is an Equal Opportunity Employer. We do not discriminate in our hiring
practices on the basis of race, religion, color, sex, gender, identity, sexual orientation, age,
disability, national origin, religion, veteran status, or any other status protected under federal,
state, or local law.
All employment decisions at ___________________ are decided on the basis of candidate
qualifications, merit, and the unique needs of our business and the position.
APPLICANT INFORMATION
Applicant Name: _______________________________________________
Address: _____________________________________________________
City, State, and Zip Code: _______________________________________
Telephone: ____________________ Alternate phone: _________________
Email Address: __________________________
Date of Application: ___________________
EMERGENCY CONTACT
Contact Name: ________________________________________________
Relationship to you: ____________________________________________
Address: _____________________________________________________
City, State, and Zip Code: _______________________________________
Telephone: ____________________ Alternate phone: _________________
EMPLOYMENT POSITION
Employment Position Applied For: __________________________________
Full or Part Time_____ Full time _____ Part time
When can you begin work if you are hired? __________________________
Salary Desired: $ ____________ per ____________
Did anyone refer you to our company? If yes, who: _________________________
Have you applied to any position at our company previously? _____ Yes _____ No
If yes, when did you apply: ________________________________________
If yes, what position did you apply for: _______________________________
Do you have any friends or family working at our company? _____ Yes _____ No
If yes, name: ________________________________________
How did you hear about this position? _____________________________________
WORK ELIGIBILITY
Are you at least 18 years old?______ Yes ______ No
If offered employment, are you able to provide proof that you are legally eligible to work in the
United States? _____ Yes _____ No
How you will get to work: _________________________________________
Driver's License (State/Number): ___________________________________
Are you able to perform the essential functions of the job position with or without reasonable
accommodation? _____ Yes _____ No
Are you willing to work any shift, including nights and weekends? _____ Yes _____ No
If no, please state any limitations: ________________________________________________
If applicable, are you available to work overtime? _____ Yes _____ No
EDUCATION AND TRAINING
Please list the schools attended.
Include any other pertinent information about your education and training.
School name: ___________________________________
Address: _____________________________________________________
From: __________ To: ___________ Did you graduate? _____ Yes _____ No
Subjects studied: ___________________________________
College/University: ___________________________________
Address: _____________________________________________________
From: __________ To: ___________ Did you graduate? _____ Yes _____ No
Degree received: ___________________________________
Other: ___________________________________
Address: _____________________________________________________
From: __________ To: ___________ Did you graduate? _____ Yes _____ No
Degree received: ___________________________________
Professional licenses, qualifications, or certifications:
____________________________________________________________
Special Achievements or Awards:
____________________________________________________________
EMPLOYMENT HISTORY
Please list all jobs. Begin with the current or most recent employment. For gaps in employment,
please include explanation. Continue on an extra sheet of paper if necessary.
Name of Employer: _____________________________________
Address: _____________________________________________________
From: __________ To: ____________ Position: _______________________
Key Duties: ___________________________________________________
Reason for Leaving: ____________________________________________
Supervisor Name: ____________________ Supervisor Phone: _____________________
Name of Employer: _____________________________________
Address: _____________________________________________________
From: __________ To: ____________ Position: _______________________
Key Duties: ___________________________________________________
Reason for Leaving: ____________________________________________
Supervisor Name: ____________________ Supervisor Phone: _____________________
Name of Employer: _____________________________________
Address: _____________________________________________________
From: __________ To: ____________ Position: _______________________
Key Duties: ___________________________________________________
Reason for Leaving: ____________________________________________
Supervisor Name: ____________________ Supervisor Phone: _____________________
Military Services? ______ Yes _____ No
Branch: ___________________________________________
Years of Service: From: __________ To: ____________
Specialized skills or training: ___________________________________________________
APPLICANT’S SKILLS
Skill: _____________________________________
Level: _____ Low _____ Medium _____ High
Skill: _____________________________________
Level: _____ Low _____ Medium _____ High
Skill: _____________________________________
Level: _____ Low _____ Medium _____ High
Language: _____________________________________
Level: _____ Fluent _____ Good _____ Fair
Language: _____________________________________
Level: _____ Fluent _____ Good _____ Fair
Other skills: __________________________________________________
REFERENCES
Name: _____________________________________
Relationship: ____________________
Address: _____________________________________________________
City, State, and Zip Code: ________________________________________
Telephone: _____________________
Name: _____________________________________
Relationship: ____________________
Address: _____________________________________________________
City, State, and Zip Code: ________________________________________
Telephone: _____________________
I certify that all statements given on this application are true and complete to the best of my
knowledge. I understand that any statements found to be false or misleading give sufficient
reason not to hire me, or if hired, can be grounds for immediate termination. I authorize
___________________ to conduct any investigation deemed appropriate concerning my
application.
I authorize former employers, references, and all other individuals and organizations disclosed
herein to provide any information sought in connection with this application.
The employment is at will, meaning that the employment is subject to termination at any time,
with or without cause or notice, and at any time. I acknowledge that no written or oral
representations nor representations about the employment can alter the at will employment
status, except those which are executed by representatives at ___________________ with the
express authority to do so.
I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND
AGREE TO ITS TERMS.
APPLICANT SIGNATURE__________________________ DATE _______________
