Date of Application: 

Position(s) Applied For:

Last Name:First Name:MI

Address 1:Address 2:     

City:State:Zip Code:

Daytime Telephone Number:

Evening Phone Number:

E-Mail Address:

Social Security Number:-- 

How did you learn about us? Advertisement Employment Agency Friend Relative Walk-In Other Select One

If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No

Have you ever been employed with us before? Yes No

Are you currently employed? Yes No

May we contact your present employer? Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (Proof of citizenship or immigration status will be required upon employment) Yes No

On what Date would you be available for work?

Are you available to work:  (Select All That Apply)

Full Time     Part Time    Shift Work    Temporary

Are you currently on "Lay-Off" status and subject to recall? Yes No

Do you have a dependable means of transportation to and from work? Yes No

Have you been convicted of a felany within the last 7 years?  Yes No (Conviction will not necessarily disqualify an applicant from employment.)

EDUCATION:

High School:

Name and Address of School

Course of Study                   

Years Completed                 

Diploma Degree                   

Undergraduate College:

Name and Address of School

Course of Study                   

Years Completed                 

Diploma Degree                   

Graduate Professional:

Name and Address of School

Course of Study                   

Years Completed                 

Diploma Degree                   

Other (Specify):

Name and Address of School

Course of Study                   

Years Completed                 

Diploma Degree                   

Additional Information:

List Interests, Hobbies, and Organizations that you are/were affiliated with.

Employment Experience:

Start with your present or last job.  Include any job-related military service assignments and volunteer activities.  You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.

1.Employer:

   Address:

   Telephone Number(s)

  Job Title: Supervisor:

  Reason For Leaving:

  Dates Employed to

  Starting Hourly Rate/Salary:  Ending Hourly Rate/Salary:

  Work Performed:

2.Employer:

   Address:

   Telephone Number(s)

  Job Title: Supervisor:

  Reason For Leaving:

  Dates Employed to

  Starting Hourly Rate/Salary:  Ending Hourly Rate/Salary:

  Work Performed:

3.Employer:

   Address:

   Telephone Number(s)

  Job Title: Supervisor:

  Reason For Leaving:

  Dates Employed to

  Starting Hourly Rate/Salary:  Ending Hourly Rate/Salary:

  Work Performed:

References:

1.Name: Phone Number:

   Address:

2.Name: Phone Number:

   Address:

3.Name: Phone Number:

   Address:

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

I AGREE     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 inquireas to whether or not applications are being accepted at that time.

I AGREE     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 thi organization.

In 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.