Employment Application

Applicant Information

Last Name:

First Name:

Middle Initial

Date:

Date

Street Address:

Apartment/Unit Number:

City:

State:

ZIP Code:

Phone:

Area CodePhone Number

Email

example@example.com

Cell Phone:

Area CodePhone Number

Desired Wage:

Position Applied for:

Have you ever worked for this company?

YesNo

If yes, when:

Have you ever been convicted of a felony?

YesNo

If yes, explain:

Are you eligible to be lawfully employed in the United States? (Proof of citizenship or immigration will be required upon employment.)

YesNo

Education

High School:

Address:

Did you graduate?

YesNo

Degree:

College:

Address:

Did you graduate?

YesNo

Degree:

Other Education:

Address:

Did you graduate?

YesNo

Degree:

Professional References

1. Full Name:

Relationship:

Company:

Phone:

Area CodePhone Number

Address:

2. Full Name:

Relationship:

Company:

Phone:

Area CodePhone Number

Address:

3. Full Name:

Relationship:

Company:

Phone:

Area CodePhone Number

Address:

Employment

1. Company

Phone:

Area CodePhone Number

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

Date Hired:

Last Day:

Reason for Leaving:

May we contact your previous supervisor for a reference?

YesNo

2. Company:

Phone:

Area CodePhone Number

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

Date Hired:

Last Day:

Reason for Leaving

May we contact your previous supervisor for a reference?

YesNo

3. Company:

Phone:

Area CodePhone Number

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities

Date Hired:

Last Day:

Reason for Leaving:

May we contact your previous supervisor for a reference?

YesNo

Other

If you are under 18 can you furnish a work permit?

YesNo

Are you available to work -

Full timePart timePer diem

Preferred Shift:

On what date would you be able to start?

Date

Do you have the full physical, mental, emotional, and medical ability to do the job for which you have applied, with or without a reasonable accommodation?

YesNo

If no, please explain:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

I authorize The Casco Inn to conduct a background investigation which will include reference checks and a Criminal Records check.

Signature:

Date:

Date