An Equal Opportunity Employer
Company is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.



Applicant Information

Applicant Name	:
Home Phone	:
Other	:
Email Address	:
Current Address	:
Number and street	:
City	:
State & Zip	:
How were you referred to Company?	:
Are you applying for:
Temporary work – such as summer or holiday work? : Yes No   Regular part-time work? : Yes No   Regular full-time work? : Yes No
If hired, on what date can you start working?	:
Can you work on the weekends?	:	Yes No
Are you available to work overtime?	:	Yes No
Salary desired	:	$
Personal Information:
Have you ever applied to / worked for Company before?	:	Yes No
If yes, please explain (include date)	:
Do you have any friends, relatives, or acquaintances working for Company?	:	Yes No
If yes, state name & relationship	:
If hired, would you have transportation to/from work?	:	Yes No
Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age.)	:	Yes No
If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?	:	Yes No
If hired, are you willing to submit to and pass a controlled substance test?	:	Yes No
Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation?	:	Yes No
If no, describe the functions that cannot be performed	:
(Note: Company complies with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)
Have you ever been convicted of a criminal offense (felony or misdemeanor)?	:	Yes No
If yes, please describe the crime - state nature of the crime(s), when and where convicted and disposition of the case	:
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
Education, Training and Experience
High School:
School name	:
School address	:
School city, state, zip	:
Number of years completed	:
Did you graduate?	:	Yes No
Degree / diploma earned	:
College / University:
School name	:
School address	:
School city, state, zip	:
Number of years completed	:
Did you graduate?	:	Yes No
Degree / diploma earned	:
Vocational School:
Name	:
Address	:
City, state, zip	:
Number of years completed	:
Did you graduate?	:	Yes No
Degree / diploma earned	:
Military:
Branch	:
Rank in Military	:
Total Years of Service	:
Skills/duties	:
Related details	:
Do you speak, write or understand any foreign languages?	:	Yes No
If yes, describe which languages(s) and how fluent of a speaker you consider yourself to be.	:
Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us?	:	Yes No
If yes, please explain	:
Employment History
Are you currently employed?		Yes No
If you are currently employed, may we contact your current employer?		Yes No
Below, please describe past and present employment positions, dating back five years. Please account for all periods of unemployment. Even if you have attached a resume, this section must be completed.
Name of Employer	:
Name of Supervisor	:
Telephone Number	:
Business Type	:
Address	:
City, state, zip	:
Length of Employment (Include Dates)	:
Position & Duties	:
Reason for Leaving	:
May we contact this employer for references?	:	Yes No
Name of Employer	:
Name of Supervisor	:
Telephone Number	:
Business Type	:
Address	:
City, state, zip	:
Length of Employment (Include Dates)	:
Position & Duties	:
Reason for Leaving	:
May we contact this employer for references?	:	Yes No
Name of Employer	:
Name of Supervisor	:
Telephone Number	:
Business Type	:
Address	:
City, state, zip	:
Length of Employment (Include Dates)	:
Position & Duties	:
Reason for Leaving	:
May we contact this employer for references?	:	Yes No
References
List below three persons who have knowledge of your work performance within the last four years. Please include professional references only.
Full Name	:
Telephone Number	:
Address	:
City, state, zip	:
Occupation	:
Number of Years Acquainted	:
Full Name	:
Telephone Number	:
Address	:
City, state, zip	:
Occupation	:
Number of Years Acquainted	:
Full Name	:
Telephone Number	:
Address	:
City, state, zip	:
Occupation	:
Number of Years Acquainted	:
Attach your Resume	:
Please Read and Initial Each Paragraph, then Sign Below
I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true & correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure can be grounds for rejection of application or, if I am employed by this company, terms for my immediate expulsion from the company. I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or the company. I permit the company to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers & all other persons, corporations, partnerships & associations from any & all claims, demands or liabilities arising out of or in any way related to such examination or revelation.
Applicant's Signature:	:
Date:	: