Application For Employment

Application For Employment
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.
(PLEASE PRINT)
Position(s) Applied For
Date of Application

MonthDayYear
Date
Other

AdvertisementFriendWalk-InEmployment AgencyRelativeOther
Name

First NameMiddle NameLast Name
Address
Number
Street
City
State
Zip Code
Telephone Number(s)
Social Security Number
If you are under 18 years of age, can you provide required proof of your eligibility to work?

YesNo
Have you ever filed an application with us before?

YesNo
If Yes, give date

MonthDayYear
Date
Have you ever been employed with us before?

YesNo
If Yes, give date

MonthDayYear
Date
Are you Currently Employed?

YesNo
May we contact your present employer?

YesNo
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment.

YesNo
On what date would you be available for work?

MonthDayYear
Date
Are you available to work

Full TimePart Time
Part Time

Shift WorkTemporary
Are you currently on "lay-off" status and subject to recall?

YesNo
Can you travel if a job requires it?

YesNo
Have you been convicted of a felony within the last 7 years? Conviction will not necessarily disqualify an applicant from employment.

YesNo
If Yes, please explain
EDUCATION

	Name and Address of School	Course of Study	Years Completed	Diploma/ Degree
High School
Undergraduate College
Graduate/Professional
Other (Specify)

WORK EXPERIENCE
Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Type a question

	Answers
Employer
Address
Telephone Number
Starting/Present Job Title
Supervisor
Reason For leaving
Starting Rate/Salary
Final Rate/Salary
Work Performed
Dates Employed

May We Contact?

YesNo

Type a question

	Answers
Employer
Address
Telephone Number
Starting/Present Job Title
Supervisor
Reason For leaving
Starting Rate/Salary
Final Rate/Salary
Work Performed
Dates Employed

May We Contact?

YesNo

Type a question

	Answers
Employer
Address
Telephone Number
Starting/Present Job Title
Supervisor
Reason For leaving
Starting Rate/Salary
Final Rate/Salary
Work Performed
Dates Employed

May We Contact?

YesNo
Comments: Include explanation of any gaps in employment.
Describe any specialized training, apprenticeship, skills and extra curricular activities.
Describe any job related training received in the United States military.
List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:
ADDITIONAL INFORMATION
Other Qualifications Summarize special job related skills and qualifications acquired from employment or other experience.
SPECIALIZED SKILLS (Skills/Equipment Operated)

TerminalSpreadsheetPC/MACWord ProcessingTypewriter (Is this still a skill?? I guess we will leave it here for you to decide)Shorthand
WPM
State any additional information you feel may be helpful to us in considering your application.
Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS

OF THE JOB FOR WHICH YOU ARE APPLYING.
Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been given.

YesNo
PERSONAL/PROFESSIONAL REFERENCES Do not include family members

	Name	Phone Number	Best Time to Call	Occupation
Reference #1
Reference #2
Reference #3

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this at will' employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
Signature of Applicant

Clear
Date

MonthDayYear
Date
Full Name
SS #
Date of Birth

MonthDayYear
Date
Next of Kin
Date of most recent physical examination

MonthDayYear
Date
Name and Address of Doctor
Do you have any physical disability or deformity?

YesNo
If answer is yes, please describe
Have you now or have you ever had any of the following: (answer yes or no for each)
Defective Eyesight
Skin Eruptions
Rupture
Dizziness
Heart Trouble
Rheumatism or Arthritis
Back Trouble
Diabetes
Kidney Trouble
Venereal Disease
Allergies
Tuberculosis
Defective Hearing
High Blood Pressure
Epilepsy
Silicosis
Eczema
Have you eve been injured? If yes, describe below:
Have you ever been injured?
If yes, describe below

Description of Injury

	Nature of Injury	Year	Cause of Injury	Did you receive medical or lost time Workmen's Compensation? (yes or no)
#1
#2
#3

I warrant* that the information given here is true and accurate, and authorize you to consult physicians and former employers.
Date

MonthDayYear
Date
Signed

Clear
* Warrant means that misinformation makes you subject to dismissal and may prevent you from receiving Workmen's Compensation benefits.
START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer
Last Name (Family Name)
Name

First Name (Given Name)Middle InitialOther Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)

MonthDayYear
Date
U.S. Social Security Number
Employee's E mail Address
example@example.com
Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following boxes)

1. A citizen of the United States2. A noncitizen national of the United States3. A lawful permanent resident4. An alien authorized to work until certain date
authorized to work until (expiration date, if applicable, mm/dd/yyyy)

MonthDayYear
Date
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

QR Code Section 1 Do Not Write In This Space
1. Alien Registration Number/USCIS Number
2. Form I 94 Admission Number
Foreign Passport Number
Country of Issuance
Signature of Employee

Clear
Today's Date (mm/dd/yyyy)

MonthDayYear
Date
Preparer and/or Translator Certification (check one):
Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1 I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

I did not use a preparer or translator.A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
Signature of Preparer or Translator

Clear
Today's Date (mm/dd/yyyy)

MonthDayYear
Date
Name

First Name (Given Name)Last Name (Family Name)
Address

Address (Street Number and Name)

Street Address Line 2

City or TownState

ZIP Code
Should be Empty:

Application For Employment

(PLEASE PRINT)

EDUCATION

WORK EXPERIENCE

ADDITIONAL INFORMATION