Employment Application

PLEASE READ CAREFULLY
Note: Fields marked with a * require an answer. Please use "N/A" for "not applicable" if necessary. Applicants may be required to complete and sign a paper application for employment upon interview.
Attach Resume:
*Email:
Applying for:

Applicant Information

*First Name:
*Last Name:
MI:
*Address:
Apartment/Unit #
*City
*State
*Zip
*Phone:
Referred By:
Date of Birth
Social Security #
Driver's License #
State Issued
Date Available:
Salary Expected:
I can work:
 Weekends    Evening    Night
U.S. Citizen:
   Yes    No
If not, are you authorized to work in the U.S.?:
 Yes     No
Languages Spoken:
*Have you ever worked for this company?:
 Yes   
 No
If yes, when?:
------ To ------
*Have you ever been convicted of a felony?
(No felonies within the past 20 yrs, Class A within the last 10 yrs and Class B within the last 5 years):
 Yes   
 No
If yes, explain briefly:


Education

High School:
Address:
Graduate:
Yes No
Degree:
College:
Address:
Graduate:
Yes No
Degree:
Other:
Address:
Graduate:
Yes No
Degree:

References

Please list three references not related to you, whom you have known at least one year.
Name:
Occupation:
Company:
Day Phone Numbers:
Address:
Name:
Occupation:
Company:
Day Phone Numbers:
Address:
Name:
Occupation:
Company:
Day Phone Numbers:
Address:

Employment History

Company Name:
Complete Address
(w/ City, State, Zip):
Phone:
Supervisor:
Job Title:
Responsibilities:
Starting Salary:
Ending Salary:
Start Date:
(mm/dd/yyyy)
 
End Date:
(mm/dd/yyyy)
 
Reason for Leaving:
May we contact your previous employer for a reference?
 Yes    No



Military Service

Start Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
Branch:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:

Applicant's Statement

Notification and Agreement

I hereby affirm that all information in this application is true and accurate to the best of my knowledge. I understand that the company can obtain criminal history record information on applicants for employment. Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report+ may be made in connection with your application for employment. I understand that any misrepresentation or falsification of this record or failure to disclose conviction for a felony or for any offense involving moral turpitude will be considered cause for dismissal.

If you are denied employment, either wholly or partly, because of information contained in a consumer report, a disclosure will be made to you of the name and address of the consumer-reporting agency making such report.

Signature below verifies you have read the above notice and understand what it means.





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