Simple Job Application Form

Job Application

Please complete the form below to apply for a position with us.
Equal access to programs, services and employment opportunities is available to all persons without regard to race, religion, color, national origin, age, sex (including pregnancy), disability, sickle cell or hemoglobin C trait, genetic information, or any other basis protected by federal, state, and/or local law.In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include making a change to the application process; providing written materials in an alternate format such as braille, large print, or audio recording; using a sign language interpreter; using specialized equipment; or modifying testing conditions.
Full Name

First Name Middle Name Last Name
Current Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Email Address
example@example.com
Position(s) Applied for:
The best time (or time window) to call you is:
May we contact you at work?

Yes No
How did you hear about us?
Have you ever been employed here before?

Yes No
Are you lawfully authorized to work in the United States?

Yes No
Have you entered into an agreement with any former employer or other party (such as noncompetition agreement) that might, in any way, restrict your ability to work for our company?

Yes No
Available Start Date

Month Day Year
Date
What is your desired salary range or rate of pay?
Type of employment desired

Full Time Part Time Seasonal Educational Co-op Temporary
Will you travel if job requires it?

Yes No
If they have been explained to you, are you able to meet the attendance requirements of the position?

Yes No
Will you work overtime if required?

Yes No
If no, please explain:
Are you able to perform the “essential functions” of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Yes No Need more information about the job’s “essential functions" to respond.
Have you ever pleaded “guilty” or “no contest” to or been convicted of a crime? NOTE: Answering “yes” to this question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. You are not obligated to disclose convictions that have been expunged.

Yes No
Skills and Qualifications: Summarize any special training, skills, languages, licenses, bonding, certifications, and/or certificates that may assist you in performing the position for which you are applying:
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