Employment Application Form

Employment / Job Application

An Equal Opportunity Employer. We do not discriminate based on sex, gender, religion, age, race, national origin/ethnicity, sexual orientation, marital status, veteran status, or parental statuses . Reasonable Accommodation will be required as required by law.
How were you referred to us?*

Walk-InReferralNewspaper AdFacebookTwitterFriend/FamilyOther (please specify)
Name*

First NameLast Name
Birth Date

MonthDayYear
Phone Number*
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What date available to work?

MonthDayYear
Date
Desired Pay
Choose Pay Type

HourlySalary
Desired Position:
What is your preferred work schedule?

Full TimePart TimeSeasonal

What are your available hours to work?

	Monday	Tuesday	Wednesday	Thursday	Friday
From:
To:

Military Service

YesNo
If “Yes” specify what role.
Employment Eligibility

(***ANY OFFER OF EMPLOYMENT IS CONDITIONEDUPON COMPLETING AN I-9 AND PROVIDING TOAPPROPRIATE DOCUMENTS FOR IDENTITY AND WORK AUTHORIZATION. ***)
SSN#
If hired, can you provide legal eligibility and documentation to work within the U.S. ?

YesNo
Are you under the age of 18?

YesNo
Have you ever been convicted of a felony?

YesNo
If “Yes” specify.
Educational Background
Name of High School:
High School Location:
Are you a Graduate? (select one)

YesNoCurrently Enrolled
Name of College/Trade School
Degree:
Are you a Graduate? (select one)

YesNoCurrently Enrolled
Previous Employment History
Employer
Dates of Employment: Date to Date
Reason for leaving?
May we contact the previous employer?

YesNo
Employer
Dates of Employment: Date to Date
Reason for leaving?
May we contact the previous employer?

YesNo
Employer
Dates of Employment: Date to Date
Reason for leaving?
May we contact the previous employer?

YesNo
Resume and Files

Cancelof
Training and Certifications
Emergency Contact Information
I authorize my employer to contact these individuals in the event of an emergency.

Clear
References

Please list two (2) references that are familiar with your work life.
Reference
Reference
Reference
***CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM. ***I CERTIFY THAT ALL OF THE INFORMATION PROVIDED ON THE EMPLOYMENT APPLICATIONE IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE, AND I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION, INCLUDING A CRIMINAL BACKGROUND CHECK, CREDIT HISTORY CHECK, AND A DRUG TEST, AS APPLICABLE.I UNDERSTAND THAT ANY FALSE INCOMPLETE INFORMATION MAY DISQUALIFY ME FROM FURTHER CONSIDERATION FOR EMPLOYMENT AND MAY RESULT IN MY IMMEDIATE DISCHARGE IF DISCOVERED AT A LATER DATE.I AUTHORIZE THE INVESTIGATION OF ANY OR ALL STATEMENTS CONTAINED IN THIS APPLICATION AND ALSO AUTHORIZE ANY PERSON, SCHOOL, CURRENT EMPLOYER, PAST EMPLOYERS, AND OTHER ORGANIZATIONS TO PROVIDE INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND/OR OTHER RELEVANT INFORMATION THAT MAY BE USEFUL IN MAKING A HIRING DECISION. I RELEASE SUCH PERSONS AND ORGANIZATIONS FROM ANY LEGAL LIABILITY IN MAKING SUCH STATEMENTS.I HAVE READ, UNDERSTAND, AND AGREE TO THE ABOVE STATEMENTS

Clear
Should be Empty:

Employment / Job Application

Employment Eligibility

Educational Background

Emergency Contact Information