EMPLOYMENT

Employment Application

This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination based on sex, marital status, race color, age, creed, national origin, sexual orientation, military reserve membership, ancestry, religion, height, weight, use of a guide or support animal because of blindness, deafness or physical handicap, or the presence of disabilities. A conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presences of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.

POSITION APPLIED FOR:*
TODAY'S DATE:*
MM slash DD slash YYYY
Name*
First Middle Last
Email*
HOME PHONE:*
WORK PHONE:*
CURRENT ADDRESS:*
Street Address City State / Province / Region ZIP / Postal Code
PRIOR ADDRESS:*
Street Address City State / Province / Region ZIP / Postal Code
AVAILABILITY
What date can you start?*
MM slash DD slash YYYY
What category would you prefer?*
- Full Time
- Part Time
- Temporary
- Labor Pool
For which schedule are you available?*
*reasonable efforts will be made to accommodate sincerely held moral and ethical beliefs, (WI) religious beliefs and practices (All other States)
- Weekdays
- Weekends
- Evenings
- Nights
- Overtime
- Shift
- Other
List other schedule shifts you are interested in here:
JOB-RELATED SKILLS
NOTE: do not fill out any part of this section you believe to be non-job related.
If the job requires, do you have the appropriate valid driver's license?*
- YES
- NO
Name on license
DL#
Type
State of Issue
Have you had any moving violations within the last seven years?*
- YES
- NO
If yes, please describe.*
Please list any other skills, licenses or certificates that may be job-related or that you feel would be of value to this job or company.
Have you been given a job description or had the essential functions of the job explained to you?*
- YES
- NO
Do you understand the essential functions?*
- YES
- NO
Can you preform the essential functions of this job with or without reasonable accommodation?*
- YES
- NO
SECURITY
List states and counties of residence for the past seven years:*
Have you used any names or Social Security Numbers other than that given above?*
- YES
- NO
If so, please list in comments below.*
Have you been convicted of a crime in the past seven years?*
Applicant is not obligated to disclose any reference to a pre or post trial diversion program, and conviction which has been sealed, expunged or erased by the court, or, if in California, any marijuana related misdemeanor conviction entered more than two years prior to the date off this employment application. (Conviction will not necessarily be a bar to employment. In accordance with company policy and applicable state and federal laws. Factors such as age at time of the offense, remoteness of the offense, time since last conviction, nature of the job sought and rehabilitation effort will be reviewed.)
- YES
- NO
1. INCIDENT*
CITY/STATE*
CHARGE*
2. INCIDENT
CITY/STATE
CHARGE
COMMENTS
PREVIOUS EMPLOYERS
PLEASE NOTE: Your application WILL NOT BE considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical. Ask for a phone book or call information if necessary. FOR EMPLOYERS OUTHSIDE THE U.S., A CURRENT FAX NUMBER IS MANDATORY.
MOST RECENT EMPLOYER
Are you currently working for this employer?*
- YES
- NO
If yes, may we contact employer?*
- YES
- NO
COMPANY NAME*
Street Address City State / Province / Region
Phone*
Fax*
DATES EMPLOYED: FROM*
MM slash DD slash YYYY
DATES EMPLOYED: TO*
MM slash DD slash YYYY
JOB TITLE*
SUPERVISOR*
DUTIES*
SALARY (hour, week, month)*
REASON FOR LEAVING*
SECOND MOST RECENT EMPLOYER
COMPANY NAME
Street Address City State / Province / Region
Phone
Fax
DATES EMPLOYED: FROM
MM slash DD slash YYYY
DATES EMPLOYED: TO
MM slash DD slash YYYY
JOB TITLE
SUPERVISOR
DUTIES
SALARY (hour, week, month)
REASON FOR LEAVING
THIRD MOST RECENT EMPLOYER
COMPANY NAME
Street Address City State / Province / Region
Phone
Fax
DATES EMPLOYED: FROM
MM slash DD slash YYYY
DATES EMPLOYED: TO
MM slash DD slash YYYY
JOB TITLE
SUPERVISOR
DUTIES
SALARY (hour, week, month)
REASON FOR LEAVING
REFERENCES
Include only individuals familiar with your work ability. DO NOT include relatives or names of supervisors listed above.
1. NAME*
ADDRESS/PHONE*
YEARS KNOWN/RELATIONSHIP*
2. NAME*
ADDRESS/PHONE*
YEARS KNOWN/RELATIONSHIP*
EDUCATION
NOTE: Do not fill out any part of this section you believe to be non-job related.
Please indicate highest grade completed.*
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16+
If your records are under a different name than listed above, please enter that name
HIGH SCHOOL
CITY/STATE
GRADUATED
- YES
- NO
DEGREE TYPE
COLLEGE
CITY/STATE
GRADUATED
- YES
- NO
DEGREE TYPE
OTHER
CITY/STATE
GRADUATED
- YES
- NO
DEGREE TYPE
CERTIFICATION AND RELEASE
I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumers reporting bureaus, to verify any of this information. I release all former employers, persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
Signature*
Date*
MM slash DD slash YYYY