EMPLOYMENT APPLICATION

Applicants are requested not to give any information which is prohibited by federal, state or local law. All qualified applicants will receive consideration without regard to race, creed, color, religion, sex, age, national origin, or physical or mental handicap. In addition, we encourage the employment of veterans. The receipt of this application does not mean that job openings exist and does not obligate us in any way. We appreciate your interest in our organization.

PLEASE ANSWER EVERY QUESTION - If a question does not apply, put "N/A"

NAME 

Address

City, State, Zip

Telephone         Mobile/Beeper/Other Ph

Best time to call you at home is Select a Time Early Morning Morning Late Morning Early Afternoon Afternoon Evening

How long have you lived at your present address?

Previous Address

How long did you live at your previous address?

Email address

Social Security Number

Driver's License Number         State

Are there any violations on your license during the last 36 months?   Yes    No

If Yes, explain

(Answering "Yes" to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.)

If yes, provide date(s) and details

Employment Details

Position Desired

Date Available

Type of Employment    Full Time    Part Time    Temporary

What days and hours, if part time

Are you able to meet the attendance requirements of the position?   Yes    No

Salary Expectations         

Are you employed now?      Yes    No

Are you on a layoff and subject to a recall?      Yes    No

Have you ever been bonded?    Yes    No    

Have you ever been refused bond?    Yes    No

If yes, state reason and date

Have you ever been discharged or asked to resign from a job?     Yes    No

If "Yes", explain

Are you legally eligible for employment in this country?        Yes    No
(Proof of U.S. Citizenship or proper immigration status will be required upon employment.)

Are you at least eighteen (18) years of age?       Yes    No
(If no, employment is subject to verification that you are of minimum legal age.)

Does your present employer know of your plans to change employment?   Yes    No

Why do you desire to make a change?

Have you ever had a job of trust (handling money or confidential material)?    Yes    No

How much time have you lost from work during this past year? (# of Days) 

Would you have steady transportation to work?        Yes    No

What three things are most important to you in a job?

  1)   2)    3) 

Name any other experiences, skills or qualifications which you feel
would especially fit you for work with this organization?

Referral Source

Select One Advertisement Employee Relative Walk-In School Private Employment Agency Government Employment Agency Other

Name of Source

Educational Background

Grade School

School Name, City, State

From:     To:

Middle School

From:     To:

High School

School Name, City, State

From:     To:

Did you graduate?    Yes    No            Degree/Course of Study

Any other Education

School Name, City, State

From:     To:

Did you graduate?    Yes    No            Degree/Course of Study

Are you attending school or college now?   Yes    No   Where?

Will you be attending school in the future?   Yes    No  Where?

MILITARY SERVICE RECORD

Were you in the U.S. Armed Forces?   Yes    No  If yes, what branch?

Tours of Duty: From      To

Rank at Discharge

Duties in the service, including special training

Employment History

(List most recent job or volunteer activities, including military experience, first. You must include any gaps in employment, with a full explanation and dates for the gap. You must also provide a complete work history for a minimum of 15 years, if applicable. We prefer you to list all jobs held, from school forward, no matter what duration the job was held. 

Employer

Address (City, State, Zip)

Telephone

Dates of Employment:    From             To

Starting Title         Final Job Title

Immediate Supervisor and Title

Reason for Leaving

Wage/Salary -    Start per Select One Hour Day Week Month Year

                        Final  per Select One Hour Day Week Month Year

Employer

Address (City, State, Zip)

Telephone

Dates of Employment:    From             To

Starting Title         Final Job Title

Immediate Supervisor and Title

Reason for Leaving

Wage/Salary -    Start per Select One Hour Day Week Month Year

                        Final  per Select One Hour Day Week Month Year

Employer

Address (City, State, Zip)

Telephone

Dates of Employment:    From             To

Starting Title         Final Job Title

Immediate Supervisor and Title

Reason for Leaving

Wage/Salary -    Start per Select One Hour Day Week Month Year

                        Final  per Select One Hour Day Week Month Year

Employer

Address (City, State, Zip)

Telephone

Dates of Employment:    From             To

Starting Title         Final Job Title

Immediate Supervisor and Title

Reason for Leaving

Wage/Salary -    Start per Select One Hour Day Week Month Year

                        Final  per Select One Hour Day Week Month Year

Employer

Address (City, State, Zip)

Telephone

Dates of Employment:    From             To

Starting Title         Final Job Title

Immediate Supervisor and Title

Reason for Leaving

Wage/Salary -    Start per Select One Hour Day Week Month Year

                        Final  per Select One Hour Day Week Month Year

Employer

Address (City, State, Zip)

Telephone

Dates of Employment:    From             To

Starting Title         Final Job Title

Immediate Supervisor and Title

Reason for Leaving

Wage/Salary -    Start per Select One Hour Day Week Month Year

                        Final  per Select One Hour Day Week Month Year

Employer

Address (City, State, Zip)

Telephone

Dates of Employment:    From             To

Starting Title         Final Job Title

Immediate Supervisor and Title

Reason for Leaving

Wage/Salary -    Start per Select One Hour Day Week Month Year

                        Final  per Select One Hour Day Week Month Year

Employer

Address (City, State, Zip)

Telephone

Dates of Employment:    From             To

Starting Title         Final Job Title

Immediate Supervisor and Title

Reason for Leaving

Wage/Salary -    Start per Select One Hour Day Week Month Year

                        Final  per Select One Hour Day Week Month Year

Notes (work gap dates, explanation, etc):

Agreement and Release

For the purpose of this agreement and release, the organization that has provided you with this application is referred to as "the company," "this company," or "you." The facts set forth above in my application for employment are true and complete. I understand that false statements or omission of information on this application or any other employment form may lead to dismissal or denial of employment. You are hereby authorized to make any investigation of my personal history, financial, criminal, credit, and motor vehicle records through any investigative or credit agencies or bureaus of your choice. You are also authorized to administer personality profile tests and verify my background.

A criminal record or sentence is not an automatic disqualification for employment. I agree to submit to any drug or alcohol testing prior to or after employment, and I agree to submit to a medical evaluation, if required. In making this application for employment, I also understand that an investigative consumer report may be made whereby information is obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted. In exchange for the consideration of my employment application by this company, I hereby release and forever discharge this company (including its directors, officers, employees, and agents) and my past and/or present employers (their directors, officers, employees, and agents) from any liabilities which may result from an investigation of my past and/or present employment or from the disclosure of such information. I authorize the use of any information in this application to verify my statements, and I authorize the past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I understand that if my application is accepted that employment with this company at all times is employment "at will." It is further understood that this "at will" relationship may not be changed by any written document, verbal statements, or by conduct unless an authorized executive of this company specifically acknowledges such change. I further understand that my "at will" employment may be terminated at any time by this company or myself and includes no guarantee, contract, or promise of employment for any specific length of time. I understand that the first 90 days of employment is a new-hire introductory period.

By placing my initials in the box below, I hereby sign and agree to the above statement