Employment Application

APPLICATION FOR EMPLOYMENT
Position Applied For
Date of Application
Date Format: MM slash DD slash YYYY
PERSONAL
Name
First Middle Last
Present Address (Street, City, State, Zip Code)
Home Telephone Number
Message Telephone Number
If No Phone, How May We Contact You?
Are Any of Your Relatives Presently Employed With This Business Or Its Divisions?
- Yes
- No
If Yes, Who?
Have You Ever Worked For This Business Or Its Divisions Before?
- Yes
- No
If Yes, Where?
Approximate Date: Month/Year
Have You Ever Applied For Employment With This Business Or Its Divisions Before?
- Yes
- No
If Yes, Where?
Approximate Date: Month/Year
How Were You Referred?
GENERAL INFORMATION
Are You 18 years Of Age Or Older?
- Yes
- No
Only U.S. Citizens Or Aliens Who Have A Legal Right To Work In The U.S. Are Elgible For Employment. Can You, Upon Employment, Provide Genuine Documentation Establishing Your Identity And Elgibility To Be Legally Employed In The United States?
- Yes
- No
Please Check Schedule Availability
- I am available and desire to work FULL-TIME. Full-Time employees must be available for all/rotating shifts.
- I am available and desire to work PART-TIME
Monday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Tuesday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Wednesday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Thursday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Friday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Saturday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Sunday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Note: Work Schedules Are Based Upon The Needs Of The Business And May Be Subject To Change On A Weekly Basis.
Wage Expected?
Date Available For Work?
Date Format: MM slash DD slash YYYY
EMPLOYMENT HISTORY
Begin With Your Most Recent Employment (1) And Continue With All Past Employment

Employment History

Employer	Street Address	City, State, Zip Code	Your Title(s)	Employed From (mm/yyyy)	Employed To (mm/yyyy)	Starting Salary ($)	Ending Salary ($)	Your Duties	Reason for Leaving	Name & Title of Supervisor	Phone Number	Type of Business	May We Contact Employer?

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EDUCATION

Education History - List High School and any post High School education. Click the + button on the far right to add additional high schools, colleges, universities, technical colleges, or trade schools

Type of School	Name and Address Of School	Major Subject	Highest Grade Or Year Completed	Graduate?	Degree

Click the + button on the far right to add additional high schools, colleges, universities, technical colleges, or trade schools

Military
Military Training or Experience
Cover Letter
Accepted file types: jpg, pdf, docx.
Resume
Accepted file types: jpd, pdf, docx.
PERSONAL OR BUSINESS REFERENCES

Add 4 References

Name	Occupation Business Phone Number	Telephone Number	Title/Relationship

Click the + button on the right to add additional references

Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.
EEO INFORMATION
To assist us in complying with government record keeping, reporting and other legal requirements, please fill out this form. Providing this information is voluntary and refusal to provide this information will not have a negative effect on your status as an applicant or employee. This information will be kept confidential and in accordance with federal and state regulations.
Name
First Last
Date
Date Format: MM slash DD slash YYYY
Title of Position Applied For:
Gender
- Female
- Male
- Decline To Identify
Military Status
- Vietnam Era Vet
- Disabled VET
- None
- Other
- Decline To Identify
Disabled
- Yes
- No
- Decline To Identify
Ethnicity
- Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
- White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
- Black or African American: A person having origins in any of the black racial groups of Africa.
- Native Hawaiian or Pacific Islander: A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
- Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent.
- Native American or Alaska Native: A person having origins in any of the original peoples of North & South America and who maintain tribal affiliation.
- Two or More Races (Not Hispanic or Latino)
- Decline to Identify
NOTIFICATION AND AGREEMENT
Applicant Statement

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE, I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR H0W DISCOVERED.

Questions regarding this statement should be directed to any employment interviewer before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

It is the policy of the company to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status, expunged juvenile records, or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State or Local law.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.

If hired, I agree to abide by all of the company rules and regulation, and understand that, if employed, my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either the company or me, I further understand that no representation, whether oral or written by any representative or agent of the Company, at any time, can constitute a contract of employment. I understand that the Company and all Plan Administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment. No representative or agent of the company, has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the President or Executive Vice President, or to make any agreement contrary to the foregoing.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me
Signature (Type your initials)
DO NOT SUBMIT UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT
Today's Date
Date Format: MM slash DD slash YYYY
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Employment Application

APPLICATION FOR EMPLOYMENT

PERSONAL

GENERAL INFORMATION

EMPLOYMENT HISTORY

EDUCATION

Military

PERSONAL OR BUSINESS REFERENCES

Other Qualifications

EEO INFORMATION

NOTIFICATION AND AGREEMENT

Section Break

Questions?