APPLICATION FOR EMPLOYMENT
An Equal Opportunity Employer
Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. Use blank paper it
you do not have enough room on this application blank. PLEASE PRINT, except for signature on back of Application. All Information given will be held in
strict confidence.
''This application is current only for thirty (30) days, at the conclusion of which time, If you have not heard
from us and still wish to be considered for employment, it will be necessary for you to fill out a new
application.''
DATE
NAME (Print)
SOC. SEC. NO
Initial
Last
First
PRESENT ADDRESS
TEL. NO
City
Zip
State
Street
Job Applied for
Full-time
Part-time
Are you seeking:
employment?
Temporary or Summer
When are you available for employment?
RECORD OF EMPLOYMENT
Name of Next Previous Employer
Telephone
Type of Business
Address
Dates Employed
Supervisor's Name and Title
Rate of Pay
Reason for Leaving
From
To
Starting
Last
Yr.
Mo
Mo.
Yr.
Job Title and Duties
Indicate in the following space if any of these employers should not be contacted at the present time
Name of Next Previous Employer
Telephone
Type of Business
Address
Dates Employed
Supervisor's Name and Title
Rate of Pay
Reason for Leaving
From
To
Starting
Last
Yr.
Mo
Mo.
Yr.
Job Title and Duties
Name of Next Previous Employer
Telephone
Type of Business
Address
Dates Employed
Supervisor's Name and Title
Rate of Pay
Reason for Leaving
From
To
Starting
Last
Yr.
Mo
Mo.
Yr.
Job Title and Duties
Name of Next Previous Employer
Telephone
Type of Business
Address
Dates Employed
Supervisor's Name and Title
Rate of Pay
Reason for Leaving
From
To
Starting
Last
Yr.
Mo
Mo.
Yr.
Job Title and Duties
Name of Next Previous Employer
Telephone
Type of Business
Address
Dates Employed
Supervisor's Name and Title
Rate of Pay
Reason for Leaving
From
To
Starting
Last
Yr.
Mo
Mo.
Yr.
Job Title and Duties
Have you ever been convicted of any criminal offense?
NO
YES
(Conviction will not necessarily disqualify an applicant.)
If yes, please explain
Are you over 18 years of age?
NO
YES
Are you a citizen of the United States or do you have a valid work permit?
NO
YES
(Federal Law requires proof of identity and employment authorization for all new
employees)
License #
For Driving Job Only: Do you have a valid driver's license?
NO
YES
EDUCATION
EDUCATION (Circle last year completed or type under school)
SCHOOL NAME
MAJOR SUBJECTS
Elementary
7
6
8
5
High School
4
1
2
3
4
College
1
2
3
Other (Business, Vocational, Military)
If you are an experienced operator of any business machines or equipment, please list
If you are an experienced operator of any plant machines or equipment, please list
Do you type?
YES
Words per Minute
NO
Do you take shorthand?
Words per Minute
NO
YES
HEALTH
Have you ever received an award for Worker's Compensation?
Was award based on permanent disability of any kind?
YES
NO
NO
YES
Nature of injuries (explain)
Do you have any physical limitations which would prevent or impair performance of the job for which you are applying?
YES
NO
Have you missed any work during the past six months due to illness?
YES
NO
Would you take a physical examination if required?
YES
NO
REFERENCES
Give three references (not relatives or former employers)
AFFIDAVIT
I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree
that the company shall not be liable in an respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this
questionnaire. I also authorize the companies, schools, or persons named above to give any information regarding my employment, character and qualifications. I
hereby release said companies, schools or persons from all liability for any damage for issuing this information. I certify that all statements and answers to questions
about my health are true and were made by me without any reservations. I expressly waive all provisions of law prohibiting any physician. person, hospital or other
institution that has or may hereafter attend or furnish me with treatment from disclosing to the company any knowledge or information thereby acquired. I understand
that any misleading or incorrect statements may render this application void, and if employed, would be cause for termination. I also understand that if employed, either the
company or I may terminate our relationship at will, without notice or for any reason and that this employment application does not constitute an employment contract.
This Company is hereby authorized to release to any other firm or person with whom I may seek employment, any and all information concerning my employment or
application.
Date
Email Address
Name
Address
Phone
Occupation