Untitled Document

APPLICATION FOR EMPLOYMENT

ALL POTENTIAL EMPLOYEES ARE EVALUATED WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE,
MARITAL OR VETERAN STATUS, THE PRESENCE OF A NON-JOB RELATED HANDICAP OR ANY OTHER LEGALLY PROTECTED STATUS.

Position Sought: ________________________________________________________________________

How did you learn about the position? ________________________________________________________

Name_____________________________________________________________ Date________________

Address__________________________________ City___________________ State________ Zip_______

Home Phone ____________________Office Phone___________________Other Phone_________________

Email Address: ______________________________ Social Security Number:_________________________

On what date would you be available for work? ____________________ Desired Wage/Salary $_____________
Are you a U.S. citizen, or are you otherwise authorized to work in the U.S. without any restriction? [ ] Yes [ ] No
Have you ever been convicted of a felony? [ ] Yes [ ] No If yes, please describe circumstances: __________
_______________________________________________________________________________________

Have you ever been involuntarily terminated or asked to resign from any position of employment? [ ] Yes [ ] No
If yes, please describe circumstances: __________________________________________________________
_______________________________________________________________________________________
If selected for employment, are you willing to submit to a pre-employment drug screening test? [ ] Yes [ ] No

EDUCATION
School Name	Location	Years Attended	Degree Received	Major

Other training, certifications, or licenses held: ____________________________________________________
_______________________________________________________________________________________

List other information pertinent to the employment you are seeking: ___________________________________
_______________________________________________________________________________________

EMPLOYMENT

(Most Recent First.)

1. Employer_____________________________________________ Job Title_________________________

Dates Employed______________ Prior Position Held within Company (if any): _________________________

Address_________________________________ City___________________ State________ Zip_________

Phone____________________ Job Title_______________________ Supervisor_______________________

Starting Salary________________________________ Ending Salary_______________________________

Duties Performed _________________________________________________________________________

Reason for Leaving _______________________________________________________________________

2. Employer_____________________________________________ Job Title_________________________

Dates Employed______________ Prior Position Held within Company (if any): _________________________

Address_________________________________ City___________________ State________ Zip_________

Phone____________________ Job Title_______________________ Supervisor_______________________

Starting Salary________________________________ Ending Salary_______________________________

Duties Performed _________________________________________________________________________

Reason for Leaving _______________________________________________________________________

3. Employer_____________________________________________ Job Title_________________________

Dates Employed______________ Prior Position Held within Company (if any): _________________________

Address_________________________________ City___________________ State________ Zip_________

Phone____________________ Job Title_______________________ Supervisor_______________________

Starting Salary________________________________ Ending Salary_______________________________

Duties Performed _________________________________________________________________________

Reason for Leaving _______________________________________________________________________

4. Employer_____________________________________________ Job Title_________________________

Dates Employed______________ Prior Position Held within Company (if any): _________________________

Address_________________________________ City___________________ State________ Zip_________

Phone____________________ Job Title_______________________ Supervisor_______________________

Starting Salary________________________________ Ending Salary_______________________________

Duties Performed _________________________________________________________________________

Reason for Leaving _______________________________________________________________________

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in
arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days.
Any applicant wishing to be considered for employment beyond this time period should inquire as to whether
or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship
with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer
may discharge Employee at any time with or without cause. 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 specifically acknowledged in writing by
an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application

or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.