Date of Application
MM
DD
YYYY
Name
Address
Telephone
(Area Code) Number
(###)
###
####
If you are under the age of 18 years of age, do you have a work permit?
Yes
No
If you have ever worked under another name, please identify:
First Name
Last Name
Position Desired
Date You can Start Work
MM
DD
YYYY
Are you available for full-time work?
Are you available for part-time work?
Are you willing to work any shift?
If no, what shift(s) are you willing to work?
First Shift
Second Shift
Third Shift
Are there any days and/or times of the week when you would not be available to work? Please specify:
How did you learn of this job opening?
Facebook
Instagram
Current Employee
Job Recruiter
Other
Have you ever worked for this Company before?
Yes
No
If yes, when?
MM
DD
YYYY
Who was your supervisor?
Why did you leave?
Do you know anyone who works here?
Who?
Have you applied to work with us before?
When?
MM
DD
YYYY
Grade School
High School
College
Trade School
What was the last school you attended?
Did you graduate?
What degree(s) have you achieved?
What extracurriclular activities did you participate in, or special skills did you acquire, at the above selected school(s) that might be helpful with the job for which you are applying?
Are you presently employed?
Are you on layoff and subject to recall?
If yes, to where?
1. Present or Last Employer
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Kind of Business
Employer Phone
(###)
###
####
Starting Position
Final Position
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
Supervisors Name
First Name
Last Name
Title of Supervisor
Description of your work and your responsibilities:
Reason for leaving
Will you receive a satisfactory reference from this employer?
If "No", please explain:
May we contact your employer at this time?
If "No", please explain:
2. Next Previous Employer
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Kind of Business
Employer Phone
(###)
###
####
Starting Position
Final Position
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
Supervisors Name
First Name
Last Name
Title of Supervisor
Description of your work and your responsibilities:
Reason for leaving
Will you receive a satisfactory reference from this employer?
If "No", please explain:
3. Next Previous Employer
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Kind of Business
Employer Phone
(###)
###
####
Starting Position
Final Position
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
Supervisors Name
First Name
Last Name
Title of Supervisor
Description of your work and your responsibilities:
Reason for leaving
Will you receive a satisfactory reference from this employer?
If "No", please explain:
4. Next Previous Employer
Employer Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Kind of Business
Employer Phone
(###)
###
####
Starting Position
Final Position
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
Supervisors Name
First Name
Last Name
Title of Supervisor
Description of your work and your responsibilities:
Reason for leaving
Will you receive a satisfactory reference from this employer?
If "No", please explain:
If you are hired, can you submit verification of your legal right to work in the United States? ( e.g., driver's license, passport, visa, green card)?
Have you ever been discharged or asked to resign by an employer?
If yes, please explain:
Do you have a valid driver's license?
License number:
State:
Have you had any accidents in the last five years?
If yes, please give details:
Have you been cited for any moving violations in the last five years?
Has your driver's license ever been suspended, revoked, denied, or cancelled?
If yes, please explain:
Have you even been in the United States Armed Services?
If yes, what branch?
Describe any skills you acquired in the Service that would be useful to the job for which you are applying for:
1. Name
Occupation
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Relationship to Applicant:
2. Name
Occupation
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Relationship to Applicant:
3. Name
Occupation
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Relationship to Applicant:
All of the information I have supplied on this application is true, accurate and complete, to the best of my knowledge, and I have not knowingly withheld any information that, if known to the Company, would affect my application unfavorably. If I am hired by the Company, and if the Company discovers at any time during my employment that any of the statements or answers on this application are false, misleading or incomplete, I may be dismissed immediately from my job.
This employment application will be considered active for ninety (90) days from the date below. If I want to be considered for a job with the Company after this period of time I must fill out another application. If hired, I understand that this application becomes part of my official employment record. In consideration of my employment with the Company, I agree to abide by all the Company's rules and regulations.
If I am extended an offer of employment, I agree to submit to a medical examination that may include testing for drugs or alcohol prior to beginning work with the Company and I understand that any offer of employment is conditioned upon passing such medical examination and/or testing. I understand that if I am employed by the Company, I may be required, when job related and consistent with the Company's business needs, to undergo a medical examination. I further understand that I may be required to submit to an alcohol or drug test at any time.
I understand that nothing in this employment application creates a contract of employment between the Company and me. If I am hired by the Company, my employment and compensation are "at will," which means that my employment can be terminated, either by the Company or me, with or without cause, and with or without notice. I understand that no manager or supervisor has the authority to make any employment agreement with me, either orally or in writing, that is not an at-will agreement. Only the President of the Company has the authority to enter into an employment agreement with me for any specified period of time.
I agree to release to the Company or its designated agents, all medical information, including but not limited to files, reports, x-rays, evaluations and opinions held by medical personnel, to the extent such information is job-related and consistent with the Company's business needs, and agree to execute the necessary HIPAA-compliant release. I acknowledge that this is a general release and that if hired, it remains in effect for the duration of my employment.
In the event of my personal indebtedness to the Company, I authorize the Company to withhold from my wages such amounts as permitted by law to satisfy my obligation to the Company.
I give the Company my permission to conduct any investigation regarding the information contained in my employment application that the Company thinks is necessary to determine my qualifications for assuming a job with the Company. I give the Company my permission to contact any former employer, school, college or university, utility company, credit or finance bureau or office, any personal or professional reference, or any other appropriate source or individual for the purpose of gathering any information, personal or otherwise, that such sources may have about my character, general reputation, credit, education or employment record, and I give my consent to any such source to release to the Company whatever information they have about me. I also unconditionally release all named and unnamed sources from any and all liability which might result from furnishing any information about me.
In exchange for the Company considering my application, I agree that any claim or lawsuit I have now or in the future against the Company its subsidiaries, successors, assigns, managers, employees and/or agents must be filed by me within one year from the date of the act or omission that is the subject of my claim or lawsuit, or within the applicable statute of limitations, whichever time period is shorter. Thus, I expressly waive any statute of limitations period for any such claim or lawsuit longer than one year, regardless of the nature of the claim or action. As further consideration for these promises by me, the Company agrees to waive any statute of limitations period longer than one year from the date of the act or omission that is the subject of any claim or lawsuit it might file against me.
*
Date
MM
DD
YYYY
Digital Signature
First Name
Last Name
