Employment Application We consider applicants for employment without regard to race, color, religion, creed, gender, national origin, age, disability or any other factor whose consideration is prohibited by applicable law. First Name Last Name Middle Name Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Telephone 1 Telephone 2 Telephone 3 E-mail Address Position(s) Applied For Have the essential functions of the position for which you are applying been explained to you? Yes No Are you able to perform the essential functions of the position? Yes No (You may answer “yes” if reasonable accommodations may be required.) Who referred you to the Company Advertisement Walk-in inquiry Agency Friend Relative Other (If other please specify) If Other Date available for work MM slash DD slash YYYY Wage / Salary desired Are you available to work overtime if required? Yes No Are you available to work Full time Part time Temporary Summer If under 18 years of age, can you provide proof of your eligibility to work? Yes No NA Can you travel if a job requires it? Yes No Have you ever been convicted of a misdemeanor? Yes No Have you ever been convicted of a felony? Yes No A misdemeanor and/or felony conviction does not disqualify you from being offered employment.Have you ever been employed with us before? Yes No If yes, give date MM slash DD slash YYYY Have you ever filled an application with us before? Yes No If yes, give date(s) MM slash DD slash YYYY List any friends / relatives employed by the companyList any affiliations with the Company's competitors, subcontractors, suppliers or vendors Are you legally eligible to work in the US? (Note: Verification will be required upon hire) Yes No Education High SchoolName Location Years Completed Course of Study Degree Undergraduate CollegeName Location Years Completed Course of Study Degree Graduate / ProfessionalName Location Years Completed Course of Study Degree Post Graduate, Business, Technical, OtherName Location Years Completed Course of Study Degree Professional Certificates & LicensesName Location Years Completed Course of Study Degree Work Experience Employer #1Employer Name Job Title Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Work PerformedAddress Phone Supervisor Hourly Rate/Salary May we contact this employer? Yes No Reason for LeavingEmployer #2Employer Name Job Title Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Work PerformedAddress Phone Supervisor Hourly Rate/Salary May we contact this employer? Yes No Reason for LeavingEmployer #3Employer Name Job Title Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Address Phone Supervisor Hourly Rate/Salary May we contact this employer? Yes No Reason for LeavingEmployer #4Employer Name Job Title Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Address Phone Supervisor Hourly Rate/Salary May we contact this employer? Yes No Reason for LeavingList professional, trade, business or civic activities and offices held. You may exclude anything that would directly or indirectly disclose race, color, religion, sex, national origin or any other protected classification.Have you ever been discharged or asked to resign from a prior position with any employer? If yes, please explain the circumstances.Describe any specialized training, apprenticeships or skills you possess, including any job related training in military.Personal/ Professional References (Do not list former employers or relatives.)NameOccupationPhone Number Add Remove APPLICANT’S CERTIFICATION AND AUTHORIZATION READ CAREFULLY I affirm that all of the above information is true, correct and complete. I understand that any information provided by me above and/or in connection with my application for employment that is found to be false, incomplete or misrepresented in any respect will cancel further consideration of this application or subject me to immediate discharge from the Company whenever it is discovered. I believe that information concerning my performance as an employee, as well as information concerning my personal habits, conduct, deportment, as well as the information outlined hereinabove; will assist me in obtaining employment with the Company. Therefore, in consideration for the Company’s act of considering me for employment, I hereby agree to release and hold harmless the Company, together with its officers, agents, employees, affiliated corporations, subsidiaries, successors and assigns, from any and all liability in any way related to the investigation of my suitability for employment with the Company, including, but not limited to, any liability relating to contact and/or discussions with any of my employers, relatives, and/or acquaintances (past and/or present.) Moreover, I specifically authorize any person (natural or otherwise) to make full response to any inquiry in connection with my application for employment with the Company, and I release any such persons from all liability arising there from. I understand and acknowledge that in the event I am employed by the Company, my employment is not for any specific length of time but, rather, is of an “at-will” nature, which means that I may resign at any time and the Company may terminate my employment at any time with or without cause. I understand that no present or future employee handbook, policy manual, work rules or publication constitutes an employment agreement or contract. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is acknowledged in writing signed by both me and an authorized executive of the Company. I agree
