Position(s) applied for
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Date
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MM
DD
YYYY
Name
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First Name
Last Name
Email
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
###
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Transportation
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If hired, do you have a reliable means of transportation to get to work?
Age
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Are you at least 18 years old?
Work Permit
If you are under 18 years of age, can you furnish a work permit?
Driver's License Number
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If the job you are applying for requires driving, please provide your Driver's License Expiration Date
MM
DD
YYYY
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Have you been convicted of a crime?
If yes, state the nature of the offense and disposition of the case. Include dates and places. (NOTE: The existence of a criminal record does not constitute an automatic bar to employment.)
Military Service
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Are you a veteran?
If yes, give dates of service from these dates
MM
DD
YYYY
If still serving, leave this date blank
MM
DD
YYYY
Skills
List any special skills or training.
Type of employment
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Full time
Part time
Temporary Employment
Preferred Shift
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What hours and shift(s) would you prefer to work?
List times you are NOT available to work?
Additional Hours
Are you willing to work: (check all that apply)
Current Employment
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Are you currently employed?
Start Date
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If hired, when would you be able to start?
MM
DD
YYYY
Past Employment
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Have you ever worked for this organization before?
Friends/Family
List any friends or relatives employed by this company:
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Have you ever been discharged or asked to resign from any position?
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If applicable, please refer to the attached job description for the position for which you are applying. Are you able to perform all these tasks with or without reasonable accommodation?
Please describe which tasks, if any, you will need accommodation to perform, and explain what type of accommodation you will need:
If in high school, are you enrolled in a recognized co-op program?
If yes, identify program and school
Company Name #1
Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Company Phone
(###)
###
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Date of Employment
MM
DD
YYYY
Date of Termination
MM
DD
YYYY
Job Title
Supervisor's Name/Title
Describe Duties Briefly
Specific Reason for Leaving
Company Name #2
Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Company Phone
(###)
###
####
Date of Employment
MM
DD
YYYY
Date of Termination
MM
DD
YYYY
Job Title
Supervisor's Name/Title
Briefly Describe Duties
Specific Reason for Leaving
Company Name #3
Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Company Phone
(###)
###
####
Date of Employment
MM
DD
YYYY
Date of Termination
MM
DD
YYYY
Job Title
Supervisor's Name/Title
Describe Duties Briefly
Specific Reason for Leaving
Company Name #4
Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Company Phone
(###)
###
####
Date of Employment
MM
DD
YYYY
Date of Termination
MM
DD
YYYY
Job Title
Supervisor's Name/Title
Describe Duties Briefly
Specific Reason for Leaving
Reference
*
For references purposes: Have you worked for any of these organizations or attended school under a different name?
If yes, give name and organization(s)
Contact
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May we contact the employers listed above?
If not, list the employers you do not wish us to contact and why.
Authorizations & At-Will Employment Agreement
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(please read carefully, then agree and date below)
I certify that I have personally completed this application. I declare that the information provided in this employment application is true and complete and I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification form my dismissal from employment if discovered at a later date. I agree to immediately notify this company if I should be convicted of a crime while my job application is pending or during my employment, if hired.
I authorize this company to make an investigation of all information contained in this employment application and I release from liability all companies and corporations supplying such information. I understand any false answers, statements, or implications made by me on this application or other required documents shall be considered sufficient cause for denial of employment or discharge.
I specifically authorize and direct my current and former employers to supply employment-related information to this company and do hereby release my current and former employers from liability for providing information to this company.
Upon termination of my employment for whatever reason, I release this company from all liability for supplying any information concerning my employment to any potential employer.
I authorize this company, if applicable, to request a copy of my credit report, motor vehicle driving record, and any other investigative report deemed necessary through various third-party sources. As required by law, upon request within a reasonable period of time, I will be notified as to the nature and scope of such investigations.
I hereby agree to submit to any drug test required of me, whether prior to my employment or if employed by this company at any time thereafter. If requested, I will take a post-job offer physical examination and my employment, in the event I receive medical treatment for any condition, including a physical, psychological, emotional, or psychiatric condition that is job-related, I hereby authorize the limited release and exchange of such medical information relating to my condition between the treatment provider and a company-designated physician.
AT-WILL EMPLOYMENT AGREEMENT
I understand and agree that nothing contained in this application or conveyed during any interview is intended to create an employment contract between the company and me. In addition, I understand and agree that if you employ me, in consideration of my employment, my employment and compensation will be at-will, for no definite period of time, and may be terminated at any time, for any reason, or for no reason at all. I understand that only the company’s President is authorized to change the employment-at-will status and such a change can only be done in writing. I have read, understand, and agree to the above.
Name 1
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First Name
Last Name
Date 13
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MM
DD
YYYY
