APPLICATION FOR EMPLOYMENT
An Equal Opportunity Employer
(Valid for only 90 days)
The Company reviews applications and employs persons without regard to race, creed, color, gender, religion, age, national origin,
physical or mental disability, marital status, veterans’ status, citizenship status or any other category protected by local, state or federal
law. In addition, the company makes reasonable accommodation to the needs of disabled applicants and employees, so long as this
does not create an undue hardship on the Company or threaten the health or safety of others at work. If you need assistance in
completing this application let us know and we will provide assistance. The receipt of this application does not mean that job openings
exist at our Company and does not obligate the Company in any way. We appreciate your interest in our Company
Please answer all questions. Resumes are not accepted in lieu of completion of this application. Note: This application was
designed to use with several types of job positions. Some questions may not be completely applicable to the job position
you are seeking; however, we ask that you answer all questions.
Last Name (Please Print) First Middle Social Security Number
Date
Present Address: Street City/State Zip Code Telephone
Number
Do you have the legal right to work in this country? __ Yes __ No
Have you ever been convicted of a crime other than a minor traffic violation? __ Yes __ No If Yes, give dates and explain. (attach
separate paper if necessary.) A conviction will not necessarily disqualify you from employment.
Are you over 18 years of age? __ Yes __ No Position applying for: ___________________________________________
EDUCATIONAL DATA
Print Name, Number and Street, City, State No. of Yrs. Major Course
School and Zip Code for each School Completed Degree of Study
High School
________________________________________________________________________________________________
_
College
Other
Other skills: List other job-related skills or qualifications that support your application. ___________________________
________________________________________________________________________________________________
_
________________________________________________________________________________________________
_
Honors Received: ____________________________________________________________________________________________
In order to permit a check of your work and educational records, should we be made aware of any change of name or assumed name
that you previously used? __ Yes __ No If Yes, identify names and relevant dates: ___________________________
___________________________________________________________________________________________________________
Have you had prior educational experience which relates to the job for which you are applying? __ Yes __ No
If Yes, describe:______________________________________________________________________________________________
Are you a veteran of the U.S. Military Service? __ Yes __ No If Yes, what branch of Service?_____________________
If Yes, beginning date and ending date of active duty: From:_______________To:_____________
Yr./Mo. Yr./Mo.
Date of Discharge from Military Service: _____________________
EMPLOYMENT EXPERIENCE:
ALL FORMER JOBS (List most recent job first.) Account for all time periods including unemployment, self-employment and military
service. (Attach separate paper(s), if necessary.)
Employer Dates Employed (From/To) Immediate Supervisor
__________________________________________________________________________________________________________
Address
__________________________________________________________________________________________________________
Job Title Hourly Rate/Salary (Starting/Final) Telephone No.
__________________________________________________________________________________________________________
Work Performed
__________________________________________________________________________________________________________
Reason for Leaving
Employer Dates Employed (From/To) Immediate Supervisor
__________________________________________________________________________________________________________
Address
__________________________________________________________________________________________________________
Job Title Hourly Rate/Salary (Starting/Final) Telephone No.
__________________________________________________________________________________________________________
Work Performed
__________________________________________________________________________________________________________
Reason for Leaving
Employer Dates Employed (From/To) Immediate Supervisor
__________________________________________________________________________________________________________
Address
__________________________________________________________________________________________________________
Job Title Hourly Rate/Salary (Starting/Final) Telephone No.
__________________________________________________________________________________________________________
Work Performed
__________________________________________________________________________________________________________
Reason for Leaving
Employer Dates Employed (From/To) Immediate Supervisor
__________________________________________________________________________________________________________
Address
__________________________________________________________________________________________________________
Job Title Hourly Rate/Salary (Starting/Final) Telephone No.
__________________________________________________________________________________________________________
Work Performed
__________________________________________________________________________________________________________
Reason for Leaving
Have you ever been dismissed or forced to resign from any employment? __ Yes __No If Yes, please explain.
___________________________________________________________________________________________________________
Are you now employed? __ Yes __ No Are you on a layoff? __Yes __ No Are you subject to recall? __Yes __ No
May we contact your present employer? __ Yes __ No Previous Employers? __ Yes __No
Please identify any exceptions and reasons for not contacting prior employers:____________________________________________
___________________________________________________________________________________________________________
Are there any hours, shifts or days you will not or cannot work? __ Yes __ No If Yes, explain:___________________________
___________________________________________________________________________________________________________
Do you have transportation to work? __ Yes __ No Will you work overtime if asked? __ Yes __ No
Do you have any friends or relatives who work here? __ Yes __ No
Name_____________________________________________ Relationship_________________________________________
Name_____________________________________________ Relationship_________________________________________
CHARACTER REFERENCES
List three persons not related to you, whom you have known at least one year:
NAME ADDRESS AND TELEPHONE OCCUPATION
1. _________________________________________________________________________________________________________
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
List below any other information or remarks that you wish to have considered as a part of your application for employment:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Have you filed an application here before? __ Yes __ No If Yes, give date:____________________________________
Have you ever been employed here before? __ Yes __ No If Yes, give dates:__________________________________
NOTICE TO APPLICANTS: This employer complies with the Americans With Disabilities Act of 1990. During the interview process,
you may be asked questions concerning your ability to perform job-related functions. If you are given a conditional offer of employment,
you may be required to complete a post-job offer medical history questionnaire and/or undergo a medical examination. If required, all
entering employees in the same job category will be subject to the same medical questionnaire and/or examination and all information
will be kept confidential and in separate files.
APPLICANT’S STATEMENT
I certify that the answers given herein are true and complete to the best of my knowledge. I authorize the investigation of
all matters contained in this application and hereby give the Employer permission to contact schools, previous employers,
references, and others, and hereby release the Employer from any liability as a result of such contact. I understand that
misrepresentations, omissions of facts or incomplete information requested in this application may remove me from
further consideration for employment. In addition, if employed, any misrepresentations or omissions of facts called for in
this application will be cause for dismissal at any time without any previous notice.
Applicants accepted for employment should clearly understand that while we make every effort to provide steady,
continuous work, we have no employment contracts, and we cannot guarantee the permanence of any position. Job
tenure can be affected by many factors including business/economic conditions, changes in laws or Employer policies,
conformity to our work rules, job performance, etc. And of course, employees may elect to leave on their own accord to
seek other jobs.
I understand that my employment with the Employer is for no specific term and may be terminated by me or the Employer
with or without notice or cause at any time. I further understand that no oral promise, Employer policy, custom, business
practice or other procedure (including the Employer’s Personnel Handbook or any personnel manuals) constitutes an
employment contract or modification of the at-will employment relationship between me and the Employer.
The contents of any employee handbook or personnel manuals, as well as other Employer policies and practices, are
subject to change or modification by the Employer, solely at its discretion, without notice. I also understand that no
supervisor or other official of the Employer (except its Chief Executive Officer, in writing)j has the authority to enter into
any agreement with me or to make any agreement contrary to the foregoing.
We conduct our business with the highest possible degree of safety and efficiency. Because of this, the Employer may
require applicants for employment to undergo blood and/or urinalysis screening for drug or alcohol use as part of our pre-
placement physical examination. In addition, all employees of the Employer are subject to blood tests or urinalysis
screening for drug or alcohol use.
This application will remain active for ninety (90) days. Any applicant wishing to be considered for employment beyond
ninety (90) days should reapply.
Signature_________________________________________________________________
Date___________________
This Employer is an equal employment opportunity employer. We adhere to a policy of making employment decisions
without regard to race, color, age, sex, religion, national origin, disability or marital status. We assure you that your
opportunity for employment with this Employer depends solely upon your qualifications.
