Position (s) applied for:

Referral Source:    

Personal Information:

 If necessary, best time to call you at home is

May we contact you at work? No Yes

If yes, work number best time to call

If you are under 18 and it is required, can you furnish a work permit? No Yes

If no, please explain.

Have you submitted and application here before? No Yes

If yes, give date(s) and position. From To Position

Have you ever been employed here before? No Yes

If yes, give date(s). From To

Are you legally eligible for employment in this county? Yes No

Date available for work

What is you desired salary range?

Type of employment desired Full-Time Part-Time Temporary Seasonal Educational Co-Op

Will you relocate is job requires it? Yes No

Will you travel is job requires it? Yes No

Are you able to meet the attendance requirements of the position? Yes No

Will you work overtime if required? Yes No

Of no, please explain.

Have you ever been bonded? No Yes

Have you ever pled "guilty" or "no contest" to, or been convicted of a crime? No Yes

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 and current employers, assignments or volunteer activities,
starting with the most recent.  Explain any gaps in employment in comments section below.

Comments: including explanation of any gaps in employment

Skills and Qualifications

Summarize any special 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)

A. List last three (3) schools attended, starting with the most recent. B. List number of years completed. C. Indicate degree
or diploma earned, if any. D. Grade Point Average or Class Rank. E. Major field of study. F. Minor field of study (if applicable).
 

References

List name and telephone number of three business/work references who are not related to you and are not listed on the previous page.
PLEASE INCLUDE EMAIL ADDRESS WHENEVER POSSIBLE.
 

Additional Information

List professional, trade, business or civic associations and any offices held.
Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical
disabilities, veteran/reserve, national guard, or any other similarly protected status.

List special accomplishments, publications, awards, etc.
Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical
disabilities, veteran/reserve, national guard, or any other similarly protected status.

List any additional information you would like us to consider.

Applicant 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 contact 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, resumé 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 and 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 an agreement or contract for employment for any specified period or definite duration.  I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing 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 that federal immigration laws require me to complete an I-9 Form in this regard.

By checking I Agree and typing your name in the space provided, you certify that you have read, fully understand and accept all terms of the foregoing Applicant Statement.

I Agree

Name:     Date: