APPLICATION FOR EMPLOYMENT
Equal Opportunity Employer
Important Legal Notice: An employer may not use any information provided by a job
applicant in a way which results in illegal discrimination against the job applicant under
applicable federal, state, or local law. For example, an employer may be subject to legal
liability for denying a job opportunity to an applicant on the basis of information
provided by the applicant regarding his or her educational background unless the
information is reasonably related to the applicant’s ability to perform the job or there is
an otherwise legitimate business reason.
PERSONAL INFORMATION
NAME
(Last) (first) (Middle)
ADDRESS CITY
STATE ZIP TELEPHONE
(Area Code/Number)
Are you legally authorized to work in the US: Yes No
POSITION DESIRED
POSITION SALARY/WAGES EXPECTED
DATE YOU CAN START
ARE YOU EMPLOYED NOW? CAN WE QUESTION YOUR PRESENT EMPLOYER?
HAVE YOU EVER APPLIED TO THIS COMPANY BEFORE?
IF SO, WHERE? WHEN?
(Cont.)
IMPORTANT NOTICE TO APPLICANTS
Under Illinois law, job applicants are not obligated to disclose sealed or
expunged records of conviction or arrest or expunged juvenile records of
conviction or arrest.
EMPLOYMENT HISTORY
DATES EMPLOYER AND ADDRESS JOB TITLE/DESCRIPTION OF DUTIES
1.
TO
2.
TO
3.
TO
4.
TO
EDUCATION (Complete only if marked by prospective employer as required for position)
NAME OF SCHOOL LOCATION COURSE/DEGREE
TRAINING OR SPECIAL STUDY (Complete only if marked by prospective employer as required for
position)
REFERENCES
Give the names of three persons not related to you, that you have known for at least one year.
NAME ADDRESS PHONE NO. OCCUPATION YEARS KNOWN
(Cont.)
LIST OF ESSENTIAL JOB-RELATED FUNCTIONS (These will be filled in by the prospective employer)
1.
2.
3.
4.
I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO
THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED
STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.
I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE
REFERENCES LISTED ABOVE TO GIVE ANY AND ALL INFORMATION CONCERNING MY
PREVIOUS EMPLOYMENT.
DATE: SIGNATURE:
DO NOT WRITE BELOW THIS LINE - FOR EMPLOYER USE ONLY
INTERVIEWED BY: DATE:
COMMENTS:
HIRE: YES NO
POSITION: DEPARTMENT:
SALARY/WAGE: REPORT DATE:
APPROVED:1. 2. 3.
Manager Dept. Head General Manager
All Information provided on this form by the job applicant or employer is provided voluntarily. The
Illinois Department of Employment Security (“IDES”) does not investigate or validate this information,
nor does IDES assume any legal liability or responsibility as to the accuracy, currency, quality or
validity of this information, nor does IDES make any warranties or guarantees, express or implied,
with respect to this information. By using this form, job applicants and employers agree to hold IDES
and its officers, employees and agents harmless from any cause of action which might arise as a
result of the job applicant’s or employer’s use of this form. Job applicants and employers assume the
risk of use of, and reliance on information provided through, this form. Neither IDES nor its officers,
employees or agents shall be liable under any theory, legal or equitable, for any claims or damages
related to a job applicant’s or employer’s use of this form.
