ApPLICATIoN
Fon EUpLoYMENT
We consider applications for all positions without regard to race, color, religion, creed,
gender, national origin, age, disability, sexual orientation, citizenship status, genetic
information or any other legally protected status.
(PLEASE PRINT)
Position(s) Applied For Date of Application
How Did You Learn About Us?
E Advertisement E Relative E Inquiry
n Employment Agency E Friend I Other
Last Name First Name Middle Name
Address Number Street City State Zip Code
Telephone Numbeds) Social Security Number (Voluntary)
AM
Best time to contact you at home is: PM
If you are under 18 years of age, can you provide required
proof of your eligibility to work? E Yes trNo
Have you ever filed an application with us before? E Yes trNo
If Yes, give date
Have you ever been employed with us before? ..... E Yes nNo
If Yes, give date
Do any of your friends or relatives, other than spouse, work here?......... ..... ! Yes No
Are you currently employed? ..... I Yes No
May we contact your present employer? ..... E Yes No
Are you prevented from lawfully becoming employed in this
country because of Visa or Immigration Status?
Proof of citizenship or immigration status will be required upon employment. .... I Yes No
Date available for work / / What is your desired salary range?
Are you available to work: tr Full-Time (please indicate I 2 3 shift)
tr Part-Time (please indicate Mornings Afternoon Evenings)
I Temporary (please indicate dates available 1_l_ _l_/_)
-
Are you currently on "lay-off' status and subject to recall? E Yes tr No
Can you travel if a job requires it? .............. D Yes n No
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
EnucATroN
Number of Diploma
Name and Address
'of School Years Degree
Course of Study Completed
Elementary
School
IIigh
School
Undergraduate
College
Graduate,
Professional
Other
(Specify)
Describe any specialized tr';rirring, approrticcsltip, skills ar-rcl cxtt-it-ctu't'icttlar activities
Describe any job-related training receivccl in the
EnnproYMENr ExpERTENCE
with your or last and
You may indicate national
or other protected status.
I Employer T)ates Fmn'lnrrerl
Work Performed
From Trr
Address
Telephone Number(s) Hourly Rate/Salan
Starting Final
Job Title
ls"*.^'*
Reason for Leaving
2 Employer Dates Em loved
Work Performed
From To
Address
Telephone Number(s) Houllv Rate./Salarrv
Stalting Final
Job Title
ls,rn.*iro.
Reason for Leaving
3 Employer Dates Em loved
From To Work Performed
Address
Telephone Number(s) Hourlv Rate/Salan
Starting Final
Job Title
ls,,ne.,iro.
Reason for Leaving
4 Employer Dates Em loved
From To
Work Performed
Address
Telephone Number(s) Hourly Rate/Salarv
Starting Final
Job Title
ls,rn..utso.
Reason for Leaving
If you need additional space, please continue on a separate sheet of paper.
List professional, trade, business or civic activities and offices held.
You may exclude mernbership which would reveal gender, race, religion, national oigin, age, ancestry, d"isabitity or other
protected status:
ApprrcANT's STaTEMENT
I certify that answers given herein are true and complete.
I authorize investigation of all statements contained in this application for employment as may be
necessary in arriving at an employment decision.
This application for employment shall be considered active for a period of time not to exceed 45
days. Any applicant wishing to be considered for employment beyond this time period should
inquire as to whether or not applications are being accepted at that time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any
employment relationship with this organization is of an "at will" nature, which means that the
Employee may resign at any time and the Employer may discharge Employee at any time with or
without cause.
In the event of employment, I understand that false or misleading information given in my
application or interview(s) may result in discharge. I understand, also, that I am required to abide
by all rules and regulations <lf the employer.
Signature of Applicant Date
FOR PERSONNEL DEPARTMENT USE ONLY
Arrange Interview n Yes tr No
Remarks
INTERITEWE,R DATE
Employed ! Yes n No Date of Employment
tel
Job Title Department
By
NAME AND TITLE DATE
Printing assumes no responsibilitv for the use of
This Application For Employment is sold for general use through^out the United states. Amsterdam
said form or any questio".;i-ri.'h; ;h"";;k;f ty iri. the job applicant, may violate State and/or Federal Law'
"-pi"y"i-"f
,6"h,\
v"/ Rev 1/15 Re-order Fom #23960 (23962 imprinted) @copyright 201 6 Amsterdam Printing'
Tolt Free 1-866-466-1438 or online w'amsterdamfoms'com
Amsterdam' N'Y' l20l o
f,msterdam'
AnuruoNAL INroniuATroN
Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.
SpEcrarrzED SKTLLS (Cnrcr SruslEeurpMENr OrnnarEo)
Production/Mobile
Machinery (list) Other (list)
-Terminal -Spreadsheet
Processing
-PC/MAC -Word
_Typewriter
-Shorthand
WPM WPM
-
State any qdditional inforntatiott yon lbel nuy he helpliil lo trs irt cottsiclering
-r*our altplication.
Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN
INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING
Can you perform the essential functions of the job, for which you are applying, either with or without a
reasonable accommodation? YES NO
Rnrnnnucrs
I (_)
(Name) Phone #
(Address)
2 ( _)
(Name) Phone #
(Address)
3 (_)
(Name) Phone #
(Address)
FOR PERSONNEL DEPARTMENT USE ONLY
z
t',1
Position(s) Applied For Is Open: I Yes I No
Position(s) Considered For:
Date
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ArrrRMATrvE AcuoN
Dnra RBcoRr)
Employees are treated during the hiring process and employment without regard to race, color, religion, creed, gender, national origin, age, disability,
sexual orientation, citizenship status, genetic information or any other legally protected status.
As an employerwith an Affinnative Action Pnogram, we complywith government regulations, including Affirmative Action rcsponsibilities where they apply.
Ihe purpose for this Data Record is to comply with government and other legal rcquk€ments. Periodic reports are made to the
government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information please note
that all Data Records are kept in a Confidential File and are kept seFrate from and are not a part of your Application for Employment or personnel file.
PICASE NOtC: YOUR COOPERAIION IS VOLUNTARY. INCLUSION OR D(CLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.
(PLEASE PRINT)
Last Name First Name Middle Name
Address Number Street City State Zip Code
Telephone Number(s) Social Security Number (Voluntary)
REFERRAL SOURCE:
Advertisement Employee Relative Private Employment Agency
Friend _ Inquiry Government Employment Agency Other
- -
-
COMPLETE ONLY THE SECTIONS BELOW THAT HAVE BEEN CHECKED
Current Job:
,,/
Birth Date:
V Gender: Q Male tr Female
tr White tr Hispanic or Latino tr Black or African American D Native Hawaiian or other Pacific Islander
V Ethnic Origin
B Asian fl American Indian or Alaskan Native B Two or more races
,,/, Are you a disabled individual? tr Yes D No
Check if any of the following are applicable:
O Special Disabled Veteran tr Disabled Veteran fl Recently Separated Veteran
O Other Protected Veteran tr Armed Forces Service Medal Veteran
Use
Position(s) Applied For Is Open: .l Yes trNo Date
Position(s) Considered For:
HIRED - Position: f Yes f No Start Date
EMPLOYMENT ANALYSIS REGISTER
Gender:
Race
Disabilitv
Other:
Referral Source
EEOI Category
Disposition:
Signature of Applicant Date
This Affirmative Action Data Record is for general use throughout the United States. Ansterdam Printing and Litho assumes no responsibility for the we
of said form or any questiorc shich, when reked by the employer of the job applican\ my violate State andlor Fedzral law.
Re-order Fom #31620 (31621 imprinted) Ocopyright 2013 Amsterdam Printing, Amsterdam, N Y. 12010
au'n\
l'^]
.0.sj,
Rev I l/13
Toll Free I -866-466-1438 or online rw.amsterdamfoms.com f,msterdam'
