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Employment Application

"*" indicates required fields

Position(s) applied for*

Email*

Full name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Main phone number*

Alt. phone number

Employment Experience

Please list the names of your present or previous employers in chronological order, with current or most recent employers listed first. Be sure to account for all periods. If self-employed, give the firm name and supply business references.

Name of employer

Supervisor

May we contact you?

Yes

No

Street address

Phone number

Dates employed: From

To:

Job title and duties

Reason for leaving

Name of employer

Supervisor

May we contact you?

Yes

No

Street address

Phone number

Dates employed: From

To:

Job title and duties

Reason for leaving

Name of employer

Supervisor

May we contact you?

Yes

No

Street address

Phone number

Dates employed: From

To:

Job title and duties

Reason for leaving

Have you ever been involuntarily terminated or asked to resign from any job?*

Yes

No

If yes, please explain.

Please explain any gaps in your employment history.

Please list any other experience, job-related skills, additional languages, or other qualifications that you believe should be considered in evaluating your qualifications for employment.*

Education

Please describe your educational background.

High school

Diploma/ degree

Yes

No

Area of study/ major

Specialized training, skills, or extracurricular activities

College/ university

Diploma/ degree

Yes

No

Area of study/ major

Specialized training, skills, or extracurricular activities

Graduate/ professional school

Diploma/ degree

Yes

No

Area of study/ major

Specialized training, skills, or extracurricular activities

Trade school

Diploma/ degree

Yes

No

Area of study/ major

Specialized training, skills, or extracurricular activities

Other education

Diploma/ degree

Yes

No

Area of study/ major

Specialized training, skills, or extracurricular activities

Business and Professional References

Please list three professional references of individuals who are not related to you.

Name and title

Relationship

Phone number or email

Name and title

Relationship

Phone number or email

Name and title

Relationship

Phone number or email

Personal References

Please list three people who know you well.

Name and title

Relationship and years acquainted

Phone number or email

Name and title

Relationship and years acquainted

Phone number or email

Name and title

Relationship and years acquainted

Phone number or email

General Information

1. Have you ever used another name?*

Yes

No

2. Is any additional information relative to name changes, use of an assumed name, or nickname necessary to enable a check on your work and educational record?*

Yes

No

If yes to either of the above, please explain:

3. Have you ever worked for this company before?*

Yes

No

If yes, please provide dates and positions:

4. Do your friends and relatives work for this company?*

Yes

No

If yes, name(s) and relationship(s):

5. On what date are you available to begin work?*

MM slash DD slash YYYY

6. Days/hours available to work:*

7. Are you available to work?*

Full time

Part-time

Shift work

Temporary

8. Would you have reliable transportation to and from work if hired?*

Yes

No

9. Can you travel if the position requires it?*

Yes

No

10. Can you relocate if the position requires it?*

Yes

No

11. Are you at least 18 years old?*

Yes

No

Note: If under 18, hire is subject to verification that you are of minimum legal age.

12. If hired, can you present evidence of your identity and legal right to work in this country?*

Yes

No

13. Can you perform the essential job functions you are applying for with or without reasonable accommodation?*

Yes

No

Note: We comply with the Americans with Disabilities Act and consider reasonable accommodation measures that may be necessary for qualified applicants/employees to perform essential job functions.

Applicant Statement and Agreement

Please read and initial each paragraph below. If there is anything that you need help understanding, please ask.

I, at this moment, authorize the company to thoroughly investigate my references, work record, education, and other matters related to my suitability for employment and, further, charge the prior employers and contacts I have listed to disclose to the company any letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I, at this moment, release the company, my former employers, and all other persons, corporations, partnerships, and associations from any claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure.*

Initial

In the event of my employment with the company, I understand that I must comply with all company rules and regulations.*

Initial

If hired, I understand and agree that my employment with the company is at will and that neither I nor the company is required to continue the employment relationship for any specific term. I understand that the company or I may terminate the employment relationship at any time, with or without cause or notice. I understand that the at-will status of my employment cannot be amended, modified, or altered in any way by any oral modifications.*

Initial

I understand that the safety of employees is essential to the company and that the company is committed to ensuring a safe working environment. I know that I, and every employee, have a responsibility to prevent accidents and injuries by observing all safety procedures and guidelines and following the directions of my site supervisor. I understand and agree to comply with federal, state, and local on-the-job safety and health regulations.*

Initial

I now certify that my answers are true and correct to the best of my knowledge. I certify that I, the undersigned applicant, have completed this application. I understand that any omission or misstatement of material fact on this application or any document used to secure employment shall be grounds for rejection or immediate discharge if I am employed, regardless of the time elapsed before discovery.*

Initial

I understand that if I am selected for hire, I will need to provide satisfactory evidence of my identity and legal authority to work in the United States and that federal immigration law requires me to complete an I-9 Form in this regard.*

Initial

I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed, and the remainder shall be enforceable.*

Initial

My signature attests that I have read, understand, and agree to the above terms.*

Type your name here to serve as your electronic signature.

All applicants are considered for all positions without regard to race, religion, color, sex, gender, sexual orientation, pregnancy, age, national origin, ancestry, physical/mental disability, medical condition, military/veteran status, genetic information, marital status, ethnicity, citizenship or immigration status, or any other protected classification, by applicable federal, state, and local laws. By completing this application, you seek to join a team of hardworking professionals dedicated to consistently delivering outstanding service to our customers and contributing to the financial success of the organization, its clients, and its employees. Equal access to programs, services, and employment is available to all qualified persons. Those applicants requiring an accommodation to complete the application and interview process should contact a management representative.

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