APPLICATION FOR EMPLOYMENT

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, handicap or national origin. 

PERSONAL INFORMATION

Date:
First Name:
Middle Name:
Last Name:
Present Address:
Permanent Address:
Phone Number:
Referred by:
Are you 18 years of age or older? Yes or No

EMPLOYMENT DESIRED

Position:
Date you can start:
Salary Desired:
Are you employed now? Yes or No
If so may we contact your present employer? Yes or No
Ever applied to this company before? Yes or No
If yes, then which department and when?

EDUCATION

High School Name and Location:
Years completed:
Did you graduate? Yes or No
Subjects studied:

College
Years completed:
Did you graduate? Yes or No
Subjects studied:

Trade, Graduate, Business or Correspondence School
Years completed:
Did you graduate? Yes or No
Subjects studied:

GENERAL

List any subjects of special study or research work:

List any job related skills such as computer, driver's license certifications etc.:

EMPLOYMENT HISTORY

List below your last four employers, starting with the most recent first.

JOB ONE

Start Date:
End Date:
Name and address of employer:
Phone number:
Supervisor:
Salary upon leaving:
Position:
Reason for leaving:

JOB TWO

Start Date:
End Date:
Name and address of employer:
Phone number:
Supervisor:
Salary upon leaving:
Position:
Reason for leaving:

JOB THREE

Start Date:
End Date:
Name and address of employer:
Phone number:
Supervisor:
Salary upon leaving:
Position:
Reason for leaving:

JOB FOUR

Start Date:
End Date:
Name and address of employer:
Phone number:
Supervisor:
Salary upon leaving:
Position:
Reason for leaving:

REFERENCES

List below three people not related to you, whom you have known at least one year.

Reference One

Name:
Address:
Phone Number:
Position:
Years Acquainted:

Reference Two

Name:
Address:
Phone Number:
Position:
Years Acquainted:

Reference Three

Name:
Address:
Phone Number:
Position:
Years Acquainted:

If you are to be hired by the company, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements.

AUTHORIZATION 

I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by the company. 

I understand that any employment is conditioned on a background check. I authorize the company to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, character and general reputation to the company, without giving me prior notice of such disclosure. In addition, I release the company, any former employers and all references listed above from any and all claims, demands or liabilities arising out of, or related to, such investigation or disclosure. 

I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be "at will" and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the company. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the company unless made in writing by an authorized company representative. 

If I am offered employment, I agree to submit to a medical examination and drug test, if required, before starting work. If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by the company and as permitted by law. I consent to such examinations and tests, and I request that the examining doctor disclose to the company the results of the examination, which results shall remain confidential and segregated from my personnel file. I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drug test, if required, and if I am hired a condition of my employment will be that I abide by the company's Drug and Alcohol Policy. 

I understand that acceptance of this form does not indicate there is a position open, and does not obligate the company to hire. If hired, I agree to abide by all company work rules, policies and procedures. The company retains the right to revise its policies or procedures, in whole or in part, at any time.

Date:

Signature