Employment Application

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State

Zip Code

Phone Number *

Area Code Phone Number

Evening Phone Number *

Area Code Phone Number

Driver's License State

Driver's License Number

Social Security Number *

Contact Name

First Name Last Name

Relationship to you

Address

Street Address

Street Address Line 2

City State

Zip Code

Phone Number *

Area Code Phone Number

Evening Phone Number *

Area Code Phone Number

Job Position Applied For:

Are you at least 18 years old?

Yes No

Are you willing to work any shift, including nights and weekends?

Yes No

If no, please state any limitations:

If you are offered employment, when would you be available to begin work?

Date

If hired, are you able to submit proof that you are legally eligible for employment in the United States?

Yes No

Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?

Yes No

What reasonable accommodation, if any, would you request?

Check those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience, and check the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)

	Skill Type	Years of Experience	Ability or Rating
Skill 1
Skill 2
Skill 3
Skill 4

Employer Name

Supervisor Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State

Zip Code

Job Duties

Reason for Leaving

Employer Name

Supervisor Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State

Zip Code

Job Duties

Reason for Leaving

Dates of Employment (Month/Year to Month/Year)

Employer Name

Supervisor Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State

Zip Code

Job Duties

Reason for Leaving

College/University Name and Address

Did you receive a degree?

Yes No

If yes, degree(s) received:

High School/GED Name and Address

Did you receive a degree?

Yes No

Other Training (graduate, technical, vocational):

Please indicate any current professional licenses or certifications that you hold:

Awards, Honors, Special Achievements:

Name

First Name Last Name

Relationship

Address

Street Address

Street Address Line 2

City State

Zip Code

Name

First Name Last Name

Relationship

Address

Street Address

Street Address Line 2

City State

Zip Code

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer/contractor

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize The Speech & Language Corner, PLLC to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand that I am required to submit to drug testing at hire and random testing to work with The Speech & Language Corner, PLLC. If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its CEO, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of The Speech & Language Corner, PLLC except in a specific written contract of employment signed on behalf of the organization by its CEO, has the power to alter or vary the voluntary nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

First Name Last Name Date

Employment Application

Applicant Information

Emergency Contact

Position Information

Applicant's Skills

Applicant Employment History

Applicant's Education and Training

References

CERTIFICATION