APPLICATION FOR EMPLOYMENT

EMPLOYMENT DETAILS
Position Of Employment Desired:
Will Accept:

Part-Time Full-Time Temporary
Are you able to perform the essential functions of the job you are applying for, with or without reasonable accommodation?

Yes No
Pay Desired
Date Available

Month Day Year
Date

GENERAL QUESTIONS
Are you currently on "lay-off" status with another employee and subject to recall?

Yes No
Have you ever been fired from a job or asked to resign?

Yes No
In the last 7 years, have you been convicted of a felony or released from prison? Does not exclude from hiring, but will result in immediate termination if not forthcoming.

Yes No
Excluding vacation and holidays, how many days were you tardy to work during the past and prior year?
Excluding vacation and holidays, how many days were you absent from work during the past and prior year?
How many notices of infractions or traffic citations (other than parking tickets) have you received in past five years?

EMPLOYMENT HISTORY

Most recent first. OK to include voluntary work and military experience.
Employer #1
Phone Number
Address
Job Title
Number of Employees Supervised
Employed from (Month/Year)
To (Month/Year)
Specific Duties
Hours Per Week
Supervisor
Reason For Leaving
May We Contact this Employer?

Yes No

EMPLOYMENT HISTORY CONT.

Most recent first. OK to include voluntary work and military experience.
Employer #2
Telephone Number
Address
Job Title
Number Employees Supervised
Employed From (Month/Year)
To (Month/Year)
Specific Duties
Hours Per Week
Supervisor

SIGNATURE PAGE
I certify the information contained in this application is true, correct, and complete. I understand that, if employed, false statements reported on this application may be considered sufficient cause for dismissal.
Signature of:
Applicant
Signature

Clear
Date

Month Day Year
Date
Should be Empty: