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Application for Employment

Federal and state laws prohibit discrimination in employment practices on account of race, color, religion, creed, national origin, ancestry, age, marital status, veteran status, non-job related disability or any other protected group status.

 
Last Name: First Name: Middle Name: 
Street: City:  State: Zip:
Day Phone:    Evening Phone: 
Do you have a legal right to be employed in the U.S.?      
Are you over the age of 18? 
Have you ever been convicted of a crime?
If yes, provide dates and details
How did you hear about us?
Other Description:   
Job Interest
Position Desired:     
(If part time, hours wanted)   
Wages or Salary desired:         Per: 
Other positions for which you are qualified:   
Date available to begin working:   
Were you ever employed by this organization? 
If yes, When:    Where:   
Rate of pay:    Position: 
Reason for leaving:
Education  
Fill in the information starting with the most recent school attended
Name of School, City and State Did you graduate? Major Degree GPA
Employment History
Fill in the information starting with the most employer.
Company Name:  From:  To: 
Address:  Position(s) Held: 
Phone Number:  Duties/Responsibilities:
Name of Supervisor: 
Starting Wage  Ending/Current $ Reason for Leaving:
Base Gross Income $:
 
 Amount Received $
May we contact this employer for reference? 
Company Name:  From:  To: 
Address:  Position(s) Held: 
Phone Number:  Duties/Responsibilities:
Name of Supervisor: 
Starting Wage  Ending/Current $ Reason for Leaving:
Base Gross Income $:
 
 Amount Received $
May we contact this employer for reference? 
Company Name:  From:  To: 
Address:  Position(s) Held: 
Phone Number:  Duties/Responsibilities:
Name of Supervisor: 
Starting Wage  Ending/Current $ Reason for Leaving:
Base Gross Income $:
 
 Amount Received $
May we contact this employer for reference? 
Company Name:  From:  To: 
Address:  Position(s) Held: 
Phone Number:  Duties/Responsibilities:
Name of Supervisor: 
Starting Wage  Ending/Current $ Reason for Leaving:
Base Gross Income $:
 
 Amount Received $
May we contact this employer for reference? 
Account for all unemployment other than those due to personal injury, illness or disability.
Skills
Please list any skills that may be related to the job for which you are applying.
Computer skills:
Word Processing:
Software Packages:
Programming Languages:
Other:
References
Please list three work references. If not applicable, please list three personal references other than a relative.
Name Relationship Address Phone Number
Other Job Related Information
Are there any organizations that you belong to that are job related? (Do not list any organizations that would reveal race, color, religion, creed, national origin, ancestry, age, marital status, veteran status, non-job related disability or any other protected group status.)
List any awards, publications or special accomplishments (Do not list any that would reveal race, color, religion, creed, national origin, ancestry, age, marital status, veteran status, non-job related disability or any other protected group status.)
Applicant Must Read and Sign
I hearby affirm that the information provided on this application is true and complete. I also understand that any omission or misrepresentation of information provided may result in my rejection or termination of employment.

I authorize the Company to contact and obtain information from all references listed and release any employers or persons listed from liability for any damages from furnishing such information.

In the event of my employment with the Company, I will comply with all the rules and policies of the employer. I understand that if I am employed, my employment will be at-will for no set period of time, and that my employment may be terminated for any reason at any time by either me or the company.

This certifies that I have read and fully understand the above statement.
Applicant Signature: Date: