| We are an equal opportunity employer and do not unlawfully discriminate
in employment. No question on this application is used for the purpose of limiting
or excluding any applicant from consideration for employment on a basis prohibited
by local, state, or federal law. Equal access to employment, services, and programs
is available to all persons. Those applicants requiring reasonable accommodation
to the application and/or interview process should notify a representative of
the organization |
| Contact Information |
| Name (First, Last)* |
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| Position Desired |
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| Address1* |
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| Address2 |
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| City* |
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| State* |
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| Zip* |
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| Telephone Number 1* |
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| Telephone Number 2 |
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| E-mail Address |
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| Social Security Number* |
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| Type of Employment Desired |
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| Date you will be available to start work |
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| Are you able to meet attendance requirements? Working hours are typically
10:45 am - 7:15pm |
YES
NO |
| Do you have any objection to working overtime if necessary |
YES
NO |
| Can you travel if required by this position? |
YES
NO |
| Have you ever been previously employed by this organization? |
YES
NO |
| Can you submit proof of legal employment authorization and identity? |
YES
NO |
| If you are under 18, can you furnish a work permit if it is required? |
YES
NO |
| Have you ever been convicted of a crime? |
YES
NO |
| If yes, please explain (a conviction WILL NOT automatically bar employment) |
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| How were you referred to us? |
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| Employment History |
| Employer #1 |
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| Position Held |
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| Address |
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| Telephone # |
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| Dates employed from |
From:
To:
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| Salary |
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| Job Summary |
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| Reason for Leaving |
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| Employer #2 |
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| Position Held |
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| Address |
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| Telephone # |
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| Dates employed from |
From:
To:
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| Salary |
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| Job Summary |
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| Reason for Leaving |
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| Employer #3 |
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| Position Held |
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| Address |
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| Telephone # |
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| Dates employed from |
From:
To:
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| Salary |
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| Job Summary |
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| Reason for Leaving |
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| Employer #4 |
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| Position Held |
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| Address |
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| Telephone # |
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| Dates employed from |
From:
To:
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| Salary |
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| Job Summary |
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| Reason for Leaving |
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| Other Skills and Qualifications |
| Other Skills or Qualifications (Summarize any job related training, skills,
licenses, certificates, and/or other qualifications) |
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| Educational History - High School |
| High School Attended |
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| Years Completed |
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| Special Honors |
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| College |
| Degree Earned? |
YES
NO |
| College Attended |
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| Years Completed |
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| Course of Study |
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| Special Honors |
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| Degrees Earned |
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| Technical Training |
| Technical Training |
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| Years Completed |
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| Course of Study |
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| Special Honors |
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| Degrees Earned |
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| Other |
| Other Education |
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| References |
| Reference 1
(Name, Ph #, Years Known, Relationship) |
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| Reference 2 (Name, Ph #, Years Known, Relationship) |
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| Reference 3 (Name, Ph #, Years Known, Relationship) |
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| You must read and check the box at the bottom* |
|
I hereby authorize the potential employer to contact, obtain, and verify the
accuracy of information contained in this application from all previous employers,
educational institutions, and references. I also hereby release from liability
the potential employer and its representatives for seeking, gathering, and using
such information to make employment decisions and all other persons or organizations
for providing such information. I understand that any misrepresentation or material
omission made by me on this application will be sufficient cause for cancellation
of this application or immediate termination of employment if I am employed, whenever
it may be discovered. If I am employed, I acknowledge that there is no specified
length of employment and that this application does not constitute an agreement
or contract for employment. Accordingly, either I or the employer can terminate
the relationship at will, with or without cause, at any time, so long as there
is no violation of applicable federal or state law. I understand that it is the
policy of this organization not to refuse to hire or otherwise discriminate against
a qualified individual with a disability because of that persons need for a reasonable
accommodation as required by the ADA. I also understand that if I am employed,
I will be required to provide satisfactory proof of identity and legal work authorization
within three days of being hired. Failure to submit such proof within the required
time shall result in immediate termination of employment. I represent and warrant
that I have read and fully understand the foregoing, and that I seek employment
under these conditions.
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