NAME OF COMPANY:
__________________________
An Equal Opportunity Employer
APPLICATION FOR EMPLOYMENT Instructions to Applicant:
Please fill in all spaces. If an item does not apply, write N/A. This application will not be valid and processed unless completed in full. You must identify the specific position for which you are applying as this application only applies to the position(s) for which you are applying. Furthermore, the position(s) must be open at the time of application for the application to be valid. This application will only be valid for a period of sixty (60) days from the date of application. Please print or type in ink clearly. Provide only the information requested. You must complete your own application. Failure to do any of the above will result in disqualification of your application. Date of Application
Name
LAST FIRST MIDDLE
Social Security No.
Present address
NUMBER AND STREET APT. CITY STATE ZIP CODE TELEPHONE
Position(s) applying for: [Be specific.]
From your review of the job functions for the position for which you are applying, are you able to perform the essential functions of the job? ________ Yes No Wage or salary desired: $ Date available for work:
Is there any time of the day or night, or particular days of the week, including weekends, that you are unable to work? Yes Type of employment desired: No Full time If yes, state when: Part time
If part-time, please state the number of hours and what days you are available to work: Is there any reason you could not be at work regularly on time?
How were you referred for employment? Have you applied for work with _______________________ before? Yes _______No If so, when? If yes, when? from Yes Yes No No to
Have you ever been previously employed by _______________________ ? ______ Yes ______ No Can you travel if the job requires it? Are you presently employed? Why do you wish to change jobs? Do you have any relatives working for____________________? Yes No Yes Yes No No Are you willing to work overtime? May we contact your present employer?
If yes, list the name and relationship:
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Do you have the legal right to work in the United States?
Yes
No
(If hired, proof of status will be required.) Have you ever been convicted of a crime by a civilian or military court (other than a minor traffic violation)? If so, give details: Yes No
(Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.)
EMPLOYMENT HISTORY 1.
Dates Worked: From to
List all work history, beginning with the most recent. Include period(s) of military service and selfemployment. Use additional pages if necessary. If you cannot recall any information, so note.
Last Salary: Address
Employer's Name
Job Title
Duties
Supervisor's Name
Reason for Leaving
2.
Dates Worked: From
to
Last Salary: Address
Employer's Name
Job Title
Duties
Supervisor's Name
Reason for Leaving
3.
Dates Worked: From
to
Last Salary: Address
Employer's Name
Job Title
Duties
Supervisor's Name
Reason for Leaving
4.
Dates Worked: From
to
Last Salary: Address
Employer's Name
Job Title
Duties
Supervisor's Name
Reason for Leaving
5.
Dates Worked: From
to
Last Salary: Address
Employer's Name
Job Title
Duties
Supervisor's Name
Reason for Leaving
Please account for all periods of unemployment longer than three (3) months:
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EDUCATION
NAME AND ADDRESS OF SCHOOL COURSE OF STUDY YEAR COMPLETED GRADUATED? DEGREE
High School
1 2 3 4
Yes
No
College 1 2 3 4 Yes No
Other 1 2 3 4 Yes No
List any additional work experience, education, skills, information, licenses, certifications, or special study relating to position applied for or of general interest not listed above:
Do you have experience operating heavy machinery? _______ Yes ________ No If so, please list the type and years of experience operating that machinery.
________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________
For any special licenses listed above, please complete the following: Type: Number: State: National: Expiration Date:
Number of years of experience at that level: Type: Number: State: National: Expiration Date:
Number of years of experience at that level: Type: Number: State: National: Expiration Date:
Number of years of experience at that level:
Is any additional information necessary to enable a check of your records such as a change of name, use of an assumed name, or nickname? _______ Yes _______ No If yes, please explain:
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If hired, would you be willing to perform other jobs as needed?
IF YOU ARE APPLYING FOR A CLERICAL POSITION, PLEASE COMPLETE THE FOLLOWING: Do you have experience with Microsoft Office? Yes No If yes, list type and amount (including experience with specific Microsoft Office products:
________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ Typing: WPM
All applicants are considered for employment without regard to race, color, sex, age, religion, national origin, disability, or military veteran status.
IMPORTANT: READ CAREFULLY
I hereby authorize all of my prior employers, credit bureaus, the officials of all schools which I have attended or been associated with, any person named above on this application blank, all public officials, and any other person or entity to give any information regarding my employment, personal habits, ability, criminal record, or any other relevant information they may have regarding me whether or not it is on their records. I hereby release said employers, schools, public officials and other persons and entities, from any and all liability for any damage whatsoever which might result from their revealing or furnishing this information. I understand that an investigation may be made whereby information is obtained through personal interviews with neighbors, friends, and others with whom I am acquainted, as well as from credit bureaus. This may include information as to character, general reputation, personal characteristics, credit history or mode of living. I know that I have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of information concerning the nature and scope of this investigation. I understand and accept that as part of the application and employment process, and/or during employment with Company I may be asked to submit to physical examinations which may include testing for alcohol and drugs, and/or be fingerprinted, all in accordance with law. By signing this application, I hereby agree to submit to such examinations and release all persons and companies from any liability arising out of such examinations, tests and fingerprintings. I further agree that the examining person may disclose to Company or its representative the results of same. If employed, I agree to conform to all policies, practices and procedures of Company and acknowledge that these may be changed, interpreted, withdrawn, or amended by Company at any time, at Companys sole option and without any prior notice to me. I consent and agree that Company shall have the right to search my personal property located on Company property, along with Companys desks, closets, et cetera, for the purpose of investigating possible violations of companys rules/policies. This also includes access to my telephone conversations and e-mails or other types of electronic communications. I further acknowledge that my employment, or any offer of employment, if such is made, may be terminated, with or without cause, and with or without prior notice, at any time, even after acceptance, at the option of Company or myself. I understand that no representative of Company has any authority to enter into any agreement with me of any nature and do hereby state that none has so been asserted to me by anyone. I HEREBY STATE THAT ALL FACTS GIVEN ARE CORRECT TO THE BEST OF MY KNOWLEDGE AND ANY MISREPRESENTATION OR OMISSION ON MY PART IS CAUSE FOR REJECTION OR TERMINATION.
Signature of Applicant
Date
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