Employment Application

Employee Name

Social Security Number

Address

Street Address Line 2

CityState

Zip

Email Address (mandatory)*

example@example.com

Phone Number

Date of Birth

Date

Driver's License #

State Issued

License Type

Emergency Contact Name

Relationship

Emergency Contact Phone Number

Our Company is an equal opportunity employer and will consider all applicants for all positions equally without regard to their race, sex, age, color, religion, national origin, veteran status or any disability. This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered. I also understand that I may be required to complete additional testing to fulfill the application process. The company requests three (3) days advance notice for any accommodations necessary to complete the application process. The company will make every reasonable effort to provide an effective accommodation, if feasible.

Are you authorized to work in the U.S. for any employer?

YesNo

Have you ever been convicted of, plead guilty to, or served probation for any crime (excluding minor traffic violations) Including DWI?

YesNo

If yes, state the offense, location, date and disposition

Offense, City-State

Disposition of charges

Date

Do you have any obligations or other reasons which would limit your ability to travel or work overtime: If yes, please explain

Would you be willing to relocate?

YesNo

Position

Employment Desired

Full TimePart TimeTemporary

Date You Can Start

Date

Salary Desired

Do you have any friends/relatives working for our company? if so what is the name of the employee

Have you ever applied/worked for our company before? If yes, please state when and where you applied and/or worked

How did you learn of our company and/or position?

Are you now or do you expect to be engaged in any other business or employment?

YesNo

Are there any days or hours you would be unable or unwilling to work? If yes, please specify those days or hours you would be unable or unwilling to work

Education (Name,Address City,State & phone#)

Use this space below to describe why you are interested in working for our company. List those skills and abilities which you feel particularly qualify you for a position with us.

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self employed, give firm name and supply business references. Previous Employers (last job 1st, company name, address, position, salary & phone)

Give three personal references, not relatives or former employers. (name, Phone# & relationship to you).

I certify that my answer to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading, or otherwise incorrect statements made on this application form or during any interviews may be grounds for my immediate discharge. I hereby authorize the Company to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against those individuals for defamation, invasion of privacy or any other reason because of their statements. I agree that, if I am employed, I will abide by all rules and regulations of the company. I understand that the taking of drug and alcohol tests, when given pursuant to company policy, are a condition of continued employment and refusal to take such tests when asked will be grounds for my immediate termination. I further understand that nobody in the Company is authorized to enter into any written or verbal employment contracts with me for any definite period of time without the express written consent of the President of the Company. I also understand that my employment is "at-will" and may be terminated by myself or by the company at any time for any reason at all, with or without prior notice.

Signature

Date

NOTE: This application will remain active for sixty (60) days, after which applicants must reapply for available positions.

Employment Application

EMPLOYMENT DESIRED:

PHONE