Employment Application

Applicant Instructions

1. Please read "APPLICANT NOTE" below.
2. Complete both pages.
3. If more space is needed to complete any question, use comments sections.
4. PLEASE NOTE "NOT APPLICABLE" IF NOT ANSWERING A QUESTION

Applicant 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 processor, 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 orientation, 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 examined by a medical professional designated by the company.

Name*

Email*

Home Phone*

Work Phone*

Current Address*

Prior Address*

For Which Position Are You Applying?*

What Date Can You Start?*

What Category Would You Prefer?*

For Which Schedule Are You Available?**

Weekdays
Weekends
Nights
Overtime
Holiday

*Reasonable efforts will be made to accommodate religious beliefs and practices.

JOB-RELATED SKILLS

If the job requires, do you have the appropriate valid drivers license?*

Yes
No

Name on License*

DL#*

Type*

State of Issue*

Have you had any moving violations?*

Yes
No

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?*

Yes
No

Do you understand these essential functions?*

Yes
No

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

Yes
No

List languages in which you are fluent:*

SECURITY

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

Have you used any names other than given above? If so, please list in comments, below.*

Yes
No

Have you been convicted of a crime in the past seven years? If so, please describe in the boxes below.*

Yes
No

(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 the offense, remoteness of the offense, time since last conviction, nature of the job sought and rehabilitation effort will be reviewed.)

FIRST INCIDENT*

CITY/STATE*

CHARGE*

SECOND INCIDENT*

CITY/STATE*

CHARGE*

COMMENTS*

PREVIOUS EMPLOYERS

PLEASE NOTE. Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical.

MOST RECENT EMPLOYER

Company Name*

City*

State*

Phone*

Are you currently working for this employer?*

Yes
No

If yes, may we contact?*

Yes
No

From*

To*

Job Title

Supervisor Name*

Duties*

$*

Per**

Reason For Leaving*

SECOND MOST RECENT EMPLOYER

Company Name*

City*

State*

Phone*

From*

To*

Job Title*

Supervisor Name*

Duties*

$*

Per**

Reason For Leaving*

THIRD MOST RECENT EMPLOYER

Company Name*

City*

State*

Phone*

From*

To*

Job Title*

Supervisor Name*

Duties*

$*

Per**

Reason For Leaving*

REFERENCES

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

NAME*

ADDRESS/PHONE*

YEARS KNOWN/RELATIONSHIP*

NAME*

ADDRESS/PHONE*

YEARS KNOWN/RELATIONSHIP*

EDUCATION

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

Please list highest grade completed.*

If your school records are under a different name than listed on page 1, please enter that name:*

High School Name*

High School City/State*

Graduate?*

Degree?*

College*

College City/State*

Graduate?*

Degree?*

Other Education*

Other Education City/State*

Graduate?*

Degree?*

Attach Resume?

CERTIFICATION AND RELEASE

Consent*

I agree to the 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 questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in
rejections of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information. I authorize all former employers, persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited.

Date*

Signature*

Applicant Instructions

Applicant Note

JOB-RELATED SKILLS

SECURITY

PREVIOUS EMPLOYERS

MOST RECENT EMPLOYER

SECOND MOST RECENT EMPLOYER

THIRD MOST RECENT EMPLOYER

REFERENCES

EDUCATION

CERTIFICATION AND RELEASE

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