Employment Application

If you prefer to download, print and submit application in person. You can download it in Microsoft Excel format here: Application.xlsx


Application Instructions:

If you need help filling out this application form or for any phase of the employment process, please notify the person that gave you this form and every effort will be made to accommodate your needs in a reasonable amount of time.

1. Please read the "Applicant Note" below.
2. Complete all blanks of this form.
3. If more space is needed to complete any question, use comments section at the bottom of this page.
4. Please note "Not Applicable" if not answering a question.
5. Some packets may include an Affirmative Action Questionnaire. This information is being gathered for affirmative action under Section 503 of the Rehabilitation Act of 1973. The information requested is voluntary and will be kept confidential. An applicant will not be subject to any adverse treatment for refusing to complete the questionnaire.
6. DO NOT FILL OUT ANY OTHER ATTACHED FORMS OR PAGES UNTIL INSTRUCTED.


Today's Date:

First Name:

Middle Name:

Last Name:

Social Security Number:

Home Phone:

Work Phone:

Current Address:

Pior Address:

Your Email:


Availability:

For which position are you applying?

What date can you start?

What date can you start?

What category would you prefer?
Full TimePart Time


Which schedules are you available?
WeekdaysWeekendsOvertime



Security:


List states and counties of residence for the past seven years.

Have you used any names or Social Security Numbers other than given above?
YesNo

If yes, Please list in comments below.

Have you been convicted of a crime in the past seven years?
YesNo

If yes, Please list in comments below. (Conviction will not necessarily be a bar to employment. In accordance with company policy and applicable state and federal laws, factors such as age at time of offense, remoteness of the offense, time since last conviction, nature of the job sought and rehabilitation effort will be reviewed.)



REFERENCES

Include only individuals familiar with your work ability. Do not include relatives.

Reference No. 1


Name:

Years Known:

Address:

Relationship:


Reference No. 2


Name:

Years Known:

Address:

Relationship:


EDUCATION


High School Name:

City & State

Graduate?
YesNo

College or University Name:

City & State

Graduate?
YesNo

Additional Training, Certificates, and Skills List Below: City: State:


Third Most Recent Employer:


Are you currently working for this employer?
YesNo

Can we contact?
YesNo

Start Date:

End Date:

Company Name:

Company Phone:

State:

City:

Email:

Fax:

Job Title:

Salary :

Supervisor Name:

Is this rate per Hour, Week or Month?

Reasons for Leaving?

Application Note*

This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination because of sex, marital status, race, color, age, creed, national origin, sexual orientations, military reserve membership, ancestry, religion, height, weight, use of a guide or support animal because of blindness, deafness or physical handicap, or the presence of disabilities. A felony conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.



JOB-RELATED SKILLS

NOTE: Do not fill out any part of this section you believe to be non-job related.


If the job requires, do you have the appropriate valid driver's license?
YesNo

Name on License:

DL Number:

State:

Type:

Have you had any moving violations? If Yes Please Describe:

Please list any other skills, licenses or certificates that may be job-related or that you feel would be of value to this job or company.

Have you been given a job description or had the essential functions of the job explained to you?
YesNo

Do you understand these essential functions?
YesNo

Can you perform the essential functions of this job with or without reasonable accommodation?
YesNo

List languages in which you are fluent.



Previous Employers

Please Note: Your application may not be considered unless each question in this section is answered. We will make every effort to contact previous employers, the correct numbers of past employers are critical. Ask for a phone book or call information if you need.


Most Recent Employer:


Are you currently working for this employer?
YesNo

Can we contact?
YesNo

Start Date:

End Date:

Company Name:

Company Phone:

State:

City:

Email:

Fax:

Job Title:

Salary :

Supervisor Name:

Is this rate per Hour, Week or Month?

Reasons for Leaving?

Second Most Recent Employer:


Are you currently working for this employer?
YesNo

Can we contact?
YesNo

Start Date:

End Date:

Company Name:

Company Phone:

State:

City:

Email:

Fax:

Job Title:

Salary :

Supervisor Name:

Is this rate per Hour, Week or Month?

Reasons for Leaving?



CERTIFICATION AND RELEASE

I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing quesTons and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false informaTon, omissions or misrepresentaTons of facts called
for in this applicaTon, whether on this document or not, may result in rejecTon of my applicaTon or discharge at any Tme during my employment. I authorize the company and/or its agents, including consumer reporTng bureaus, to verify any of this informaTon. I authorize all former employers, persons, schools, companies
and law enforcement authoriTes to release any informaTon concerning my background and hereby release any said persons, schools, companies and law enforcement authoriTes from any liability for any damage whatsoever for issuing this informaTon. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug tesTng to detect the use of illegal drugs prior to and during employment.


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