Employment Application Form
Name
*
First Name
Middle Name
Last Name
Email
*
example@example.com
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If required for the position, do you have a valid driver's license?
*
Yes
No
If hired, would you have reliable transportation to and from work?
*
Yes
No
Have you ever worked under a different name?
*
Yes
No
What other name have you worked under?
Do you know anyone who is working here?
*
Yes
No
Who do you know working here and what's your relationship to them?
Have you ever worked for the company?
*
Yes
No
When did you work here? and what position?
Can you meet all attendance required?
*
Yes
No
Why not?
Position Desired:
*
Date Available:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Salary Desired:
*
Hourly Wage
Annual Salary
Type of Employment Desired
*
Regular
Full-time
Temporary
Part-Time
Days and hours available for work :
*
Would you be willing to work overtime?
*
Yes
No
Education Information
Rows
Name & Location of School
Course of Study
Did you graduate?
Certificate or Degree Earned
High School
Yes
No
College/University
Yes
No
Post-Graduate
Yes
No
Business/Trade Technical
Yes
No
Yes
No
References (Business references we can contact who have knowledge of your employment & competence)
Rows
Name of Reference
Title & Company
Phone Number
Your Work Relationship with this person
1
2
3
Employment Information (Begin with current or most recent employer)
Rows
Company Name
Phone
Dates Employed
Address
Job Title
Supervisor Name
Starting Pay
Ending Pay
Reason for Leaving
May we contact this employer?
1
Yes
No
2
Yes
No
3
Yes
No
Yes
No
Please account for any time you were not employed in the last 10 years, or since leaving school.
Rows
Time Period
Reason for unemployment
Please read carefully, initial each paragraph, and sign below.
*
Rows
Initial
I hereby certify that I have not withheld or misstated any material facts that might adversely affect my application for employment and that the answers given by me are true and correct. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or any document used to secure employment shall be grounds for rejection of this application, or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I hereby authorize the Company to thoroughly investigate my references, work record, education, and other matters related to my suitability for employment, and further, I authorize my former employers listed in this application to speak to officials of and disclose to the Company any and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. I authorize disclosure of this information in compliance with and in waiver of my rights under applicable privacy legislation.
I understand that some positions at the Company require criminal background checks and that a criminal conviction is not an automatic disqualification for hire. I understand that I will be notified and will provide additional written authorization in the case a criminal background check is required for a position that I may hold.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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