Employment Application

Position(s) applied for:

Date:

How did you learn about us?	Advertisement	Friend	Walk-in
How did you learn about us?	Employment Agency	Relative	Other

Last Name:

First Name:

Middle Name:

Street:

City:

State:

Zip Code:

Telephone Number:

Daytime:

Evening:

Social Security Number:

Can you provide required proof of eligibility to work if you are under 18 years of age?	Yes	No
Have you ever applied to work with us before? If yes, give date:	Yes	No
Have you ever been employed by us before? If yes, give date:	Yes	No
Are you employed currently?	Yes	No
If yes to the above, may we contact your present employer?	Yes	No
Visa or immigration Status can prevent you from lawfully becoming employed in this country. Can you provide proof of citizenship of immigration status?	Yes	No
You will be available for work on what date?
Would you prefer - Full time Part time Shift work Temporary
Are you presently on "lay-off" status and subject to recall?	Yes	No
Do you object to travel, if a job required it?	Yes	No
Within the last 7 years, have you been convicted of a felony? (conviction will not necessarily disqualify an applicant from employment)	Yes	No
If yes, please give an explanation:

Education

	Name and Location	Years Completed	Diploma/ Degree	Course of Study
Elementary School
High School
Undergraduate College/University
Graduate/ Professional

Indicate any specialized training, apprenticeship, skills and extra-curricular activities:

Describe honors you have received:

Other information you feel may be helpful to us in considering your application:

Indicate any foreign language you can speak, read and/or write.

	Speak	Read	Write
Fluent
Good
Fair

Have you ever held any professional, trade, business, or civic positions or offices? (You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, handicap, or other protected status.) Please list:

References:
	Name	Address	Phone
1.
2.
3.

Have you ever had any job-related experience in the United States military?
If yes, please describe:

Are you physically or otherwise unable to perform the duties of the position for which you are applying?

Yes

Employment Experience

Employer	Dates Employed		Work Performed
	From	To
Address
Telephone number(s)	Hourly Rate / Salary
	Start	Final
Supervisor	Job title
Reason for leaving

Employer	Dates Employed		Work Performed
	From	To
Address
Telephone number(s)	Hourly Rate / Salary
	Start	Final
Supervisor	Job title
Reason for leaving

Applicant's Statement

To the best of my knowledge, I certify that the answers given here are true and complete.

I agree to authorize any necessary investigation of all statements contained in this application for employment to arrive at an employment decision.

Applications for employment shall be considered active for a 45-day period. If you wish to be considered for employment beyond this time period, you must inquire as to whether or not applications are being accepted at that time.

I, the applicant, understand and acknowledge that any employment relationship with this organization is of an "at will" nature, unless otherwise defined by applicable law. An Employee may resign at any time and the Employer may discharge any Employee at any time with or without cause. Furthermore, this "at will" relationship may not be altered by any written document or by conduct unless such alteration is specifically acknowledged in writing by an authorized executive of this organization.

I also understand that false or misleading information given in this application or interview(s) may result in discharge if employment results from this application. Finally, I understand that I am required to abide by all rules and regulations of the employer.

By submitting this form you are agreeing to the above statement and will be legally bound by its policies.

After Submitting this form you will be taken to a Security Screening form that you must complete.