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Position(s) applied for __________________Date of application
___________________ Name ________________________________Social Security
# _________________________
Address
_______________________________________________________________________
Telephone# ( ) _____________Mobile/Beeper/Other Phone # (
)_____________E-mail Address:_____________
If you are under 18, and it is required, can you furnish a work
permit?………………………. YES NO
If no, please
explain_________________________________________________________________________________
Have you ever been employed here before? If yes, give dates and positions
YES NO ____________________________
Are you legally eligible for employment in this country? YES NO
Date available for work _______________What is your desired salary range?
$____________
Type of employment desired Full Time Part-Time Temporary Seasonal
Educational Co-Op
Are you able to meet the attendance requirements of the position? YES NO
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?
YES NO
If yes, please provide date(s) and
details_____________________________________________
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.
Employment History
Provide the following information of your past three (3) employers,
assignments or volunteer activities, starting with the most recent .
| From To |
|
Employer Telephone # |
|
Starting Job Title/Final Job Title |
|
Address |
|
Immediate Supervisor and Title |
|
Summarize the Nature of Work Performed and Job Responsibilities |
| May We
Contact For Reference? Yes No Later |
|
|
| Reason
for Leaving |
|
Hourly
Rate/Salary Start $ Per Final $ Per |
| From To |
|
Employer Telephone # |
|
Starting Job Title/Final Job Title |
|
Address |
|
Immediate Supervisor and Title |
|
Summarize the Nature of Work Performed and Job Responsibilities |
| May We
Contact For Reference? Yes No Later |
|
|
| Reason
for Leaving |
|
Hourly
Rate/Salary Start $ Per Final $ Per |
| |
| From To |
|
Employer Telephone # |
|
Starting Job Title/Final Job Title |
|
Address |
|
Immediate Supervisor and Title |
|
Summarize the Nature of Work Performed and Job Responsibilities |
| May We
Contact For Reference? Yes No Later |
|
|
| Reason
for Leaving |
|
Hourly
Rate/Salary Start $ Per Final $ Per |
Skill and Qualifications
Summarize any training, skills, licenses and/or certificates that may qualify
you as being able to perform job related functions in the position for which you
are
applying.________________________________________________________________________________________________________
Educational Background (if job related)
| Name and Location |
Number of years completed |
Did you Graduate? |
Course Study |
| High School |
|
|
|
| College |
|
Major Degree |
|
| Other |
|
|
|
References
| Name |
Telephone |
Number of Years Known |
| |
|
|
| |
|
|
| |
|
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Applicant Statement
I certify that all information I have provided in order to apply for and
secure work with the employer is true, complete and correct.
I understand that nay information provided by me that is found to be false,
incomplete or misrepresented in any respect, will be sufficient cause to (I)
cancel further consideration of this application, or (ii) immediately discharge
me from the employer’s service, whenever it is discovered.
I expressly authorize, without reservation, the employer, its
representatives, employees or agents to contact and obtain information from all
references (personal and professional), employees, public agencies, licensing
authorities and educational institutions and to otherwise verify the accuracy of
all information provided by me in this application, resume or job interview. I
hereby waive any and all rights and claims I may have regarding the employer,
its agents, employees or representatives, for seeking, gathering and using such
information in the employment process and all other persons, corporations or
organizations for furnishing such information about me.
I understand that the employer does not unlawfully discriminate in employment
and no question on this application is used for the purpose of limiting or
excusing any applicant from consideration for employment on a basis prohibited
by applicable local, state or federal law.
I understand that this application remains current for only 30 days. At the
conclusion of that time, if I have not heard from the employer and still wish to
be considered for employment, it will be necessary to reapply and fill out a new
application.
If I am hired, I understand that I am free to resign at any time, with or
without prior notice, and the employer reserves the same right to terminate my
employment at any time, with or without prior notice, except as may be required
by law. This application does not constitute an agreement or contract for
employment for any specified period or definite duration. I understand that no
supervisor or representative of the employer is authorized to make any
assurances to the contrary and that no implied, oral or written agreements
contrary to the foregoing express language are valid unless they are in writing
and signed by the employer’s president.
I also understand that if I am hired, I will be required to provide proof of
identity and legal authority to work in the United States and that federal
immigration laws require me to complete an I-9 Form in this regard.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
I certify that I have read, fully understand and accept all terms of the
foregoing Applicant Statement.
Signature of Applicant
______________________________________________________________________ Date
_____________________
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