Employment Application

Details
  1. Walk-inEmployeeAdvertisementWebsiteOther InternetSchoolJob FairStaffing AgencyGovernment Employment AgencyOther
  2. Home PhoneCellular/Other
  3. YesNo
  4. YesNo
  5. YesNo
  6. YesNo
  7. YesNo
  8. YesNo
  9. YesNo
  10. YesNo
  11. YesNo
  12. YesNo
  13. Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)?
    This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

    YesNo

  14. YesNo
Employment History - Employer #1

Starting with your most recent employer, provide the following information.

  1. YesNoLater
  2. SalaryHourly
  3. SalaryHourly
Employment History - Employer #2

Starting with your 2nd most recent employer, provide the following information.

  1. YesNoLater
  2. SalaryHourly
  3. SalaryHourly
Employment History - Employer #3

Starting with your 3rd most recent employer, provide the following information.

  1. YesNoLater
  2. SalaryHourly
  3. SalaryHourly
Employment History - Employer #4

Starting with your 4th most recent employer, provide the following information.

  1. YesNoLater
  2. SalaryHourly
  3. SalaryHourly
Employment History - Continued
  1. YesNo
Skills and Qualifications
  1. Word ProcessingSpreadsheetPresentationE-mailInternetOther
Educational Background - School #1

Starting with your most recent school attended, provide the following information.

  1. DiplomaGEDDegreeCertificationOther
Educational Background - School #2

Starting with your 2nd most recent school attended, provide the following information.

  1. DiplomaGEDDegreeCertificationOther
Educational Background - School #3

Starting with your 3rd most recent school attended, provide the following information.

  1. DiplomaGEDDegreeCertificationOther
Educational Background - School #4

Starting with your 4th most recent school attended, provide the following information.

  1. DiplomaGEDDegreeCertificationOther
References - #1

List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors.
If not applicable, list three school or personal references who are not related to you.

References - #2
References - #3
Related Information

To what job-related organizations (professional, trade, etc.) do you belong?

Exclude memberships that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status.

List special accomplishments, publications, awards, etc.

Exclude memberships that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status.

In your current or a previous job, have you ever written instructions or directions to be followed by employees or customers?

  1. YesNo
Applicant Statement
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.
I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.
I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.
I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.
If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.
I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an 1-9 Form in this regard.
This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, genetic information, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer).The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
  1. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. (type "yes" below to certify)

* Required