Employment Application

Federal law prohibits discrimination on the basis of race, color, religion, disability, sex, or national origin, as well as
discrimination on the basis of age against persons over the age of 40. Some state and city legislation prohibits discrimination
on the basis of age, marital status, sexual preference, race, color, religion, sex, national origin, or any other basis prohibited
by law. This employment application is only active for 30 days. After this time period a separate employment application must
be submitted in order to be considered for employment.

Date _____________________

Please print clearly

Personal Information
First Name _____________________________ Middle _____________________ Last ____________________________________
Street Address __________________________________________ Social Security No. ___________________________________
City/State/Zip _____________________________________________________ Phone (_____) _____________________________
How did you find out about this job? Newspaper Website Referral Other _____________________________________
If hired, do you have a reliable means of transportation to get to work? Yes No What is it? ___________________________
Minimum salary expected __________________________________________ Are you at least 18 years old? Yes No
If the job you are applying for requires driving: Drivers License No. _____________ State Issued _____ Expiration Date ________
Are you legally eligible for employment in the U.S.? Yes No (Proof of U.S. citizenship or immigration status will be required if hire.)
Have you been convicted of a felony in the last seven years? Yes No Are you currently on parole? Yes No
Are you currently awaiting trial? Yes No Are you currently on deferred adjudication? Yes No (circle one)
If you answered yes to any of the previous question, state the nature of the offense and disposition of the case. Include dates and
places. (NOTE: Felony convictions or the existence of a criminal record do not constitute an automatic bar to employment.)
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________

Are you seeking? Temporary Full-time Part-time What position(s) are you applying for? _____________________________
What hours and shift(s) would you prefer to work? _______________________________ Not prefer? ______________________
Please indicate any shift(s) you would not be available to work. ______________________________________________________
Are you willing to work overtime? Yes No Weekends? Yes No Holidays? Yes No
Are you currently employed? Yes No If hired, when would you be able to start? __________________________________
Have you ever worked for this organization before? Yes No If yes, name used: ___________________________________
List any friends or relatives employed by this company: ___________________________________________________________
Are you on layoff and subject to recall? Yes No
Have you ever been discharged or asked to resign from any position? Yes No
If yes, please describe: ______________________________________________________________________________________
How many days have you missed from/been late to school or work within the last year other than approved vacation, sick, or
disability leave? ____________________ Please describe: _____________________________________________________________________
____________________________________________________________________________________________________________________________________

Education
Elementary: 1 2 3 4 5 6 7 8
Name of School: __________________
Location of School: ________________

Secondary: 9 10 11 12 G.E.D
Name of School: __________________
Location of School: ________________

If currently in high school, are you enrolled in a recognized co-op program? Yes No

College: 1 2 3 4 5 6 7 8
Name of School: __________________
Location of School: ________________
Degree & Major: __________________
Minor: _________________________

If yes, please name program and school? ___________________________________________________________________________

Work History
1. Company _________________________________________ Phone No. with Area Code (_____) _________________________
Address __________________________________________ City/State/Zip __________________________________________
Dates of Employment: From __________ To ____________ Salary: Beginning ______________ Ending _________________
Job Title _________________________________________ Supervisors Name & Title _______________________________
Describe duties for leaving: __________________________________________________________________________________
Specific reason for leaving: __________________________________________________________________________________
2. Company _________________________________________ Phone No. with Area Code (_____) _________________________
Address __________________________________________ City/State/Zip __________________________________________
Dates of Employment: From __________ To ____________ Salary: Beginning ______________ Ending _________________
Job Title _________________________________________ Supervisors Name & Title _______________________________
Describe duties for leaving: __________________________________________________________________________________
Specific reason for leaving: __________________________________________________________________________________
3. Company ________________________________________ Phone No. with Area Code (_____) _________________________
Address _________________________________________ City/State/Zip __________________________________________
Dates of Employment: From __________ To ____________ Salary: Beginning ______________ Ending _________________
Job Title _________________________________________ Supervisors Name & Title _______________________________
Describe duties for leaving: __________________________________________________________________________________
Specific reason for leaving: __________________________________________________________________________________
May we contact all the employers listed above? Yes No If not, tell us which one(s) you do not wish us to contact and why:
___________________________________________________________________________________________________________
How many jobs have you had in the last five years not listed above? ___________________________________________________
Why are you seeking a new position at this time? __________________________________________________________________
List any business-related outside interests and organizations youre active in: ____________________________________________
__________________________________________________________________________________________________________

Military Experience
Are you a veteran Yes No If yes, please give dates of service. From __________ To ____________
List any special skills or training ________________________________________________________________________________
I authorize this company to make an investigation of all information contained in this employment application and I release from
liability all companies and corporations supplying such information. I understand any false answers, statements, or implications made
by me on this application or other required documents shall be considered sufficient cause for denial of employment or discharge. Upon
termination of my employment for whatever reason, I release this company from all liability for supplying any information concerning
my employment to any potential employer. I authorize this company, if applicable, to request a copy of my credit report, motor vehicle
driving record, and any other investigative report deemed necessary through various third party sources. As required by law, upon
request within a reasonable period of time, I will be notified as to the nature and scope of such investigations. I hereby agree to submit
to any drug test required of me, whether prior to my employment or if employed by this company at any time thereafter. If requested, I
will take a post-job offer physical examination and my employment will be conditional upon passing such examination. During such
employment, in the event I receive medical treatment for any condition, including a physical, psychological, emotional, or psychiatric
condition that is job-related, I hereby authorize the limited release and exchange of such medical information relating to my condition
between the treatment provider and a company-designated physician. I further understand this is an application for employment and that
no employment contract is being offered. I understand that if I am employed, such employment is for an indefinite period of time and
the company may change wages, benefits, and conditions at any time. My employment is at will. No individual with the company is
authorized to change the employment-at-will status except an officer of the company, who may do so only in writing. I have read and
understand the above.

Applicant's Signature ____________________________________________ Date __________________