Date |
|
Last Name* |
|
First Name* |
Midle Initial*
|
PRESENT ADDRESS: |
|
Street Address |
|
City |
|
State |
Zip
|
Telephone Number: |
Day number
Evening Number
|
Position applied for? |
|
When are you available for employment? |
|
Which type of employment are you seeking? |
|
After
reviewing the job description for the position to which you have
applied, are you able to perform the essential job functions with or
without reasonable accomodation? |
Yes
No |
RECORD FOR EMPLOYMENT |
1. Name of current/Most recent Employer |
|
Address |
|
Telephone Number |
|
Type of Business |
|
Dates Employed: |
From-
mo.
yr.
To-
mo.
yr.
|
Rate of Pay: |
Starting
Ending
|
Reason for Leaving |
|
Supervisor's Name and Title |
|
List the jobs you held, duties performmed, skills used or learned, advancements or promotions. |
|
May we contact your current employer? |
Yes
No |
2.
Name of next/Previous employer |
|
Address |
|
Telephone |
|
Dates Employed: |
From-
mo.
yr.
To-
mo.
yr.
|
Rate of Pay: |
Starting
Ending
|
Reason for Leaving |
|
Supervisor's Name and Title |
|
List the jobs you held, duties performmed, skills used or learned, advancements or promotions. |
|
May we contact your current employer? |
Yes
No |
2.
Name of next/Previous employer |
|
Address |
|
Telephone |
|
Dates Employed: |
From-
mo.
yr.
To-
mo.
yr.
|
Rate of Pay: |
Starting
Ending
|
Reason for Leaving |
|
Supervisor's Name and Title |
|
List the jobs you held, duties performmed, skills used or learned, advancements or promotions. |
|
May we contact your current employer? |
Yes
No |
3.
Name of next/Previous employer |
|
Address |
|
Telephone |
|
Dates Employed: |
From-
mo.
yr.
To-
mo.
yr.
|
Rate of Pay: |
Starting
Ending
|
Reason for Leaving |
|
Supervisor's Name and Title |
|
List the jobs you held, duties performmed, skills used or learned, advancements or promotions. |
|
May we contact your current employer? |
Yes
No |
4.
Name of next/Previous employer |
|
Address |
|
Telephone |
|
Dates Employed: |
From-
mo.
yr.
To-
mo.
yr.
|
Rate of Pay: |
Starting
Ending
|
Reason for Leaving |
|
Supervisor's Name and Title |
|
List the jobs you held, duties performmed, skills used or learned, advancements or promotions. |
|
May we contact your current employer? |
Yes
No |
Have you ever been convicted, entered a plea of nolo contedre or received a withheld judgment for any criminal offence? |
Yes
No
(a conviction will not necessarily disqualify an applicant. ) |
If yes, please explain: |
|
Are you over 18 year os age? |
Yes
No |
Are you authorized to work in the United States? |
Yes
No |
(Federal law requires proof of identity and employment authorization for all new employees. )
FOR DRIVING JOB ONLY:
|
Do you have a valid drivers license? |
Yes
No |
License number and state issued: |
|
|
|
School Name |
|
Last Year Completed |
|
Major Subjects |
|
College: |
|
School Name |
|
Last Year Completed |
|
Major Subjects |
|
If
you are an experienced operator of any position-related business/plant
machines or equipment, please list : other job-related skills: |
|
I authorize the Company to release to any person, firm, entity or organization with which I may seek employment in the future, any truthful information concerning my work experience with the Company. I hereby release and hold the Company harmless from any claim for releasing any truthful information within its knowledge and/or records.
I understand that any job offer that may be extended to me will be contingent upon the successful completion of a drug and alcohol test.
I certify that the answers given by me to the foregoing questions and during any interviews are true and correct without material omissions, and understand that, if employed, omissions and/or false statements on this application or during any interviews may result in dismissal. I understand and acknowledge that, if hired, my employment is for no definite period and either the Employer or I may terminate our relationship at will at any time, without notice or any reason, and that this employment application does not constitute an employment contract.
I have had an opportunity to have my questions about this statement's content and intent answered and understand its terms.
Date
Signature of Applicant
|
