Application for Employment
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodations to the application and/or interview process should notify a representative of the Human Resources Department.
Position(s) applied for date of application
Name
First
Middle
Last
Address
Street
City
ST
Zip
Telephone # Mobile/Other # E-mail
If you are under 18, and it is required, can you furnish a work permit? If no, please explain N/A Yes No
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.
Driver’s license number if driving is an essential job function State
Employment History
Provide the following information of your past four (4) employers, assignments or volunteer activities, starting with the most recent.
 From
  To
 Starting Job Title/Final Job Title
 Immediate Supervisor and Title
 May we contact for reference?
Yes No Later
 Reason for leaving
 Employer
  Telephone#
 Address
 Summarize the nature of work performed and job responsibilities
 Hourly Rate/Salary
 Start $ per     Final $ per
 From
  To
 Starting Job Title/Final Job Title
 Immediate Supervisor and Title
 May we contact for reference?
Yes No Later
 Reason for leaving
 Employer
  Telephone#
 Address
 Summarize the nature of work performed and job responsibilities
 Hourly Rate/Salary
 Start $ per     Final $ per
 From
  To
 Starting Job Title/Final Job Title
 Immediate Supervisor and Title
 May we contact for reference?
Yes No Later
 Reason for leaving
 Employer
  Telephone#
 Address
 Summarize the nature of work performed and job responsibilities
 Hourly Rate/Salary
 Start $ per     Final $ per
 From
  To
 Starting Job Title/Final Job Title
 Immediate Supervisor and Title
 May we contact for reference?
Yes No Later
 Reason for leaving
 Employer
  Telephone#
 Address
 Summarize the nature of work performed and job responsibilities
 Hourly Rate/Salary
 Start $ per     Final $ per
Skills 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 OF STUDY
 High school
 Yes No
 College
  Major/Degree
 Other
References
NAME TELEPHONE NUMBER OF YEARS KNOWN
Application 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 any 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 contract and obtain information from all references (personal and professional), employers, 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 ant 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 cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute and agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or repetitive or the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the forgoing 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 the federal immigration laws require me to complete an I-9 Form in this regard.


I UNDERSTAND THAT ANY OFFER OF EMPLOYMENT IS CONTINGENT UPON SUCCESSFULLY PASSING A DRUG TEST AND THAT A PRE-EMPLOYMENT PHYSICAL IS REQUIRED PRIOR TO THE START OF WORK.

     DO NOT SUBMIT UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

     By clicking Submit, below, I certify that I have read, fully understand and accept all the terms of the foregoing Applicant Statement.