APPLICATION FOR EMPLOYMENT

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APPLICATION FOR EMPLOYMENT
Please Answer All Questions. A Résumé Is Not A Substitute For A Completed Application.

We are an equal opportunity employer. Applications are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state, or local laws.
Position Applied For
Name:
Telephone Number:
Format: (000) 000-0000.
Alternate or Cellular Telephone Number:
Format: (000) 000-0000.
Present Address:
City:
State:
Zip Code:
How long have you lived there?
Years:
Months:
Email Address (optional)
example@example.com
Desired Salary/ Hourly Rate
YesNo
Full TimePart Time
Part-time (Specify Hours)
YesNo
Date on which you can start work if hired?

MonthDayYear
Date
YesNo
If yes, when and where did you apply?
YesNo
YesNo
If yes, provide dates of employment, location, and reason for separation from employment.
YesNo
NOTE: Answering “yes” to the above does not constitute an automatic bar to employment. The Agency will consider the nature of the crime, it’s seriousness, the substantial relation to the position’s functions and qualifications, the number of occurrences, the applicant’s age at the time of the crime, the time elapsed since the crime, the applicant’s entire work and educational history, employment references and recommendations, and the business necessity of any exclusion when required by state, local, or federal law.
If you answered yes to the preceding question, please give dates and details for each incident.
List all special technical skills that you feel qualify you for the job for which you are applying (for example, computer programming/language, software, equipment operation, special tools or machines, etc).

Education

Rows	Education	School Name and Location (Address, City, State)	Course of Study/Degree/Major	Graduate? And # of Years Attended

Type a question

Rows	LANGUAGE	FLUENT	GOOD	FAIR
Language_1
Language_2
Language_3

If applicable, list below any other names by which you have been known. Knowledge of this may be necessary to allow us to confirm your work and educational record. For example, change of name, use of an assumed name, nickname,
If applicable, list below any other names by which you have been known. Knowledge of this may be necessary to allow us to confirm your work and educational record. For example, change of name, use of an assumed name, nickname, etc.
WORK EXPERIENCE
Please list the names of your present and/or previous employers in chronological order with present or most recent employer listed first. Provide information for at least the most recent ten (10) year period. Attach additional sheets if needed. If self-employed, supply firm name and business references. You may include any verifiable work performed on a volunteer basis, internship, or military service. Your failure to completely respond to each inquiry may disqualify you from consideration for employment. “See resume” is not an acceptable answer.
Employer Name
Employer Address
Type of Business
Telephone
Format: (000) 000-0000.
Dates Employed : From

MonthDayYear
Date
Date Employed: To

MonthDayYear
Date
Job Title
Duties
Supervisor’s Name
YesNo
If No, why not?
Starting Wage
Final Wage
Reason for leaving
Employer Name
Employer Address
Type of Business
Telephone
Format: (000) 000-0000.
Dates Employed : From

MonthDayYear
Date
Dates Employed: To
Job Title
Duties:
Supervisor's Name:
YesNo
If No, why not?
Final Wage
Final Wage
Reason for leaving
Employer Name:
Employer Address:
Type of Business:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Dates Employed : From

MonthDayYear
Date
To
Job Title
Duties
Supervisor's Name:
YesNo
If No, why not?
Final Wage
Final Wage
Reason for leaving
REFERENCES
Please list the names of additional work-related references we may contact. Individuals with no prior work experience may list school or volunteer-related references.

Rows	NAME	POSITION	COMPANY	(i.e., supervisor, co worker)	TELEPHONE

Please list the names of personal references (not previous employers or relatives) who know you well that we may contact.

Rows	NAME	OCCUPATION	ADDRESS	TELEPHONE	NUMBER OF YEARS KNOWN

APPLICANT CERTIFICATION
I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on, possessing a valid driver’s license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside.

I understand that the Agency may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Agency has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law

I certify that all the information on this application, my résumé, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.

THIS AGENCY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE AGENCY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE
AGENCY IS AUTHORIZED TO ENTER INTO AN AGREEMENT-EXPRESS OR IMPLIED-WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME WITHOUT THE APPROVAL OF THE CEO.

I authorize the Agency or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I am seeking to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation which may be permitted by federal, state and/or local law If hired by this Agency, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Agency. I also understand this Agency employs only individuals who are legally eligible to work in the United States.

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTH (6) MONTHS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE.

DO NOT SIGN UNTIL YOU HAVE READ ALL OF THE INFORMATION CONTAINED IN THE APPLICATION.
Signature

Clear
Date

MonthDayYear
Date
If the applicant is a minor, the foregoing release and consent must be signed by the applicant’s parent or legal guardian. Signature by the applicant’s parent or legal guardian constitutes acknowledgement by the applicant and the parent or legal guardian that the Agency to the extent permitted by federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate test results to Agency personnel who need to know, the applicant, and the applicant’s legal guardian.
Parent/Legal Guardian (If under 18)
Witness
Should be Empty:

Please Print Clearly

APPLICATION FOR EMPLOYMENT

How long have you lived there?

WORK EXPERIENCE

REFERENCES

APPLICANT CERTIFICATION