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Application For Employment

Date*
MM slash DD slash YYYY
Apply To Location
Name
First Middle Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Social Security #
Telephone #
Other #
Emergency Contact
Phone#
Other #
Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation.)
- Yes
- No
Availability
- Temporary
- Long Term
- Same Day Assignments
- Permanent
What hours are you available?
Do you have reliable transportation?
- Yes
- No
Have you ever been convicted of a felony? (This will not necessarily affect your application.)
- Yes
- No
If yes, please describe conditions.
Education
Education
School Name and Location Year Major Degree
Employment Desired
Position applying for
Desired Salary
Employment History (Start with most recent employer)
Employer 1
Address
Telephone
Date Started
MM slash DD slash YYYY
Starting Wage
Starting Position
Date Ended
MM slash DD slash YYYY
Ending Wage
Ending Position
Name of Supervisor
May we contact?
- Yes
- No
Responsibilities
Reason for leaving
Employment History
Employer 2
Address
Telephone
Date Started
MM slash DD slash YYYY
Starting Wage
Starting Position
Date Ended
MM slash DD slash YYYY
Ending Wage
Name of Supervisor
Ending Position
May we contact?
- Yes
- No
Responsibilities
Reason for leaving
Employment History
Employer 3
Address
Telephone
Date Started
MM slash DD slash YYYY
Starting Wage
Starting Position
Date Ended
MM slash DD slash YYYY
Ending Wage
Name of Supervisor
Ending Position
May we contact?
- Yes
- No
Responsibilities
Reason for leaving
Please Read Before Signing
I certify that all information provided by me on this application is true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this application. I also authorize investigation of all statements contained in this application, including a criminal background, credit history, and drug test, as applicable. I understand that any false or incomplete information may disqualify me from further consideration for employment and may result in my immediate discharge if discovered at a later date.

I authorize my previous employers, schools, or persons listed as references to give any information regarding employment or educational record. I agree that this company and my previous employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or employment is terminated because of false statements, omissions, or answers made by myself on this application. In the event of any employment with this company, I will comply with all rules and regulations as set by the company in any communication distributed to the employees.

I understand that employment at this company is “at will,” which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis.

I hereby acknowledge that I have read and understand the above statements.
Signature
Date
MM slash DD slash YYYY
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