Employment Application

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Position Applying For

Personal Information

First Name

Initial

Last Name

Email Address

Phone Number

Drivers License Number

State

Expiration

Age

Date of Birth

If you are not a U.S. citizen, what is the basis of your eligibility for employment

Employment

Position Related Experience

Have you filed an application here before? YesNo

If yes, when?

Have you been employed here before? YesNo

If yes, when?

Are you employed now? YesNo

If yes, when would you be available to work?

Are any of your employment or educational records recorded under another name(s)? YesNo

If yes, please list?

Have you ever been convicted of a crime, or are you currently charged with a crime other than a moving traffic violation? YesNo

If yes, please explain?

Are you fluent in any foreign languages(s)? YesNo

If yes, please list?

Summarize your special skills and qualifications

Education

Graduate/Professional

School Name

Diploma/Degree

Honors Received

Describe course of study

College/University

School Name

Diploma/Degree

Honors Received

Describe course of study

High School

School Name

Diploma/Degree

Honors Received

Describe course of study

Employment Experience

List all of your work experience including military and voluntary service assignments. Begin with your present or last position. Attach additional sheet if necessary.

Employer 1

Employer

Telephone

Address

Job Title

Supervisor

Work Performed

Start Date

End Date

Hourly Rate/Salary Start

Hourly Rate/Salary End

Employer 2

Employer

Telephone

Address

Job Title

Supervisor

Work Performed

Start Date

End Date

Hourly Rate/Salary Start

Hourly Rate/Salary End

Employer 3

Employer

Telephone

Address

Job Title

Supervisor

Work Performed

Start Date

End Date

Hourly Rate/Salary Start

Hourly Rate/Salary End

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Acknowledgement

All applicants are considered for position without regard to race, color, religion, sex, national origin, age, marital or veteran status, or the presence of a non-job-related medical condition or handicap. Verification of eligibility to work in the U.S will be required if an employment offer is made.

I acknowledge that consideration of employment is contingent on the results of a reference and background check. Therefore, I hereby authorize this Company to (1) investigate the truthfulness of all statements made on this application; (2) contact my former employers and other listed references or any other persons who can verify information; (3) discuss the results of any investigation with other employees of this Company involved in the hiring process; (4) check my driving record if applicable for the target job; and (5) check my criminal record. In addition, I give my consent for all contacted persons including former employers to provide the information concerning this application, and I release each such person from liability for providing information to this Company.

I certify that the information contained in this application is correct to the best of my knowledge, and understand that falsification of this application in any detail is grounds for disqualification from further consideration or dismissal from employment in accordance with company policy. I understand that if I am hired I will submit to a test to detect the use of illegal drugs prior to and during employment.

Signature

Date

Affirmative Action Information

Note: Completion of this information is voluntary. The information supplied will be kept confidential. Refusal to provide this information will not subject the applicant to any adverse treatment and it will be used only in accordance with the Act and regulations cited below.

Executive Order 11246, as amended by Executive Order 11385 and Section 402 of the Vietnam Era Veterans Readjustment Assistance Act 1974, requires all government contractors and subcontractors with 50 or more employees and contracts from the federal government to recruit, hire, promote, and otherwise guarantee equal employment opportunity for qualified minorities, men, women, handicapped individuals and veterans in all job groups and at all levels of the work force. In order for this company to comply with this order and record this data, we ask that you complete the following.

Full Name

Position Applied For

Veteran who served on active duty for more than 180 days during the Vietnam era? YesNo

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