Employment

You must complete entire application
Applicant Information
Name (first, middle, last)      
Address (street, city, state, zip code)   Day Telephone  
Social Security #   Evening Telephone  
Are there other names under which you have worked or attended school?  Yes No If yes, please list for reference checking purposes.

 
Are you legally authorized to work in the U.S.?  Yes No (If hired, you will be required to provide proof of work authorization.)  
Are you at least 18 years old?  Yes No If not, your employment will be subject to verification that you meet state/federal minimum age requirements for the type of work you are applying for and have obtained a valid work permit.  
Have you ever been convicted of a crime or pleaded no contest for any offense or violation other than minor traffic violations?  Yes No If yes, explain 1) nature of crime, 2) date of conviction, and 3) state in which convicted. (Convictions are not an automatic bar to employment.)

Do you have any pending criminal charges against you?  Yes No If yes, describe the 1) nature of the charges, 2) date issued, and 3) county and state where issued.

Have you ever applied at this company before?  Yes No

If yes, when:
Have you ever worked at this company before?

 Yes No
If yes, when:


Position Applying For
Part-Time or Full-Time Desired Salary Preference Shift Preference When can you start?
How were you referred to the company?  Agency Walk-in Friend/Relative Newspaper School Other
Special Skills
1. If relevant, please describe word processing speed, software knowledge, and office equipment experience.
2. If relevant, please describe experience using manufacturing machines and equipment.
Education
School Name and Location (city, state) Major subjects Diploma or Degree Rec'd
High School    Yes No
College  Yes No
Graduate  Yes No
Other (specify)  Yes No
Training Courses
List any relevant training programs completed.
Course/Seminar Organization Sponsoring Content Date(s) Attended
Required License(s)
If required to drive a motor vehicle for the job applying for, state your:
1) driver's license number 2) state issued
Are you licensed with any group, association or society relating to the job for which you are applying?  Yes No  
Registration or License Number State Issued Expiration Date  
Employment History (start with most recent)
Name of Employer Telephone
Address
Job Title Employment Dates (month and year)
Name of Immediate Supervisor From To
Description of Duties
Salary — start Salary — end Reason for Leaving
If currently employed, may we contact as a reference?  Yes No  
 
Name of Employer Telephone
Address
Job Title Employment Dates (month and year)
Name of Immediate Supervisor From To
Description of Duties
Salary — start Salary — end Reason for Leaving
If currently employed, may we contact as a reference?  Yes No  
 
Name of Employer Telephone
Address
Job Title Employment Dates (month and year)
Name of Immediate Supervisor From To
Description of Duties
Salary — start Salary — end Reason for Leaving
If currently employed, may we contact as a reference?  Yes No  
 
Name of Employer Telephone
Address
Job Title Employment Dates (month and year)
Name of Immediate Supervisor From To
Description of Duties
Salary — start Salary — end Reason for Leaving
If currently employed, may we contact as a reference?  Yes No  
Employment References
List individuals familiar with your job qualifications (no relatives or personal friends).
Name Day Telephone
Evening Telephone
Address
Relationship How long known?
 
List individuals familiar with your job qualifications (no relatives or personal friends).
Name Day Telephone
Evening Telephone
Address
Relationship How long known?
 
List individuals familiar with your job qualifications (no relatives or personal friends).
Name Day Telephone
Evening Telephone
Address
Relationship How long known?
 

Please Read Carefully Before Signing This Form

  1. All information contained in this application is true and correct to the best of my knowledge and belief. I understand that misrepresentations or omissions of any kind may result in denial of employment or be cause for subsequent dismissal if I am hired.
  2. I authorize the company to investigate my responses on this application and contact any or all of my former employers or any individuals familiar with me or my employment background for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me or my employment. I voluntarily and knowingly fully release and hold harmless any person or organization that provides information pertaining to me or my employment.
  3. I understand that upon receiving a job offer, a physical examination and drug screening may be required. (Note: If this is a job requirement, you will be notified.)
  4. Regardless of whether or not I become employed by the company, I recognize that this application is not and should not be considered a contract of employment. I understand that employment at the company is on an at-will basis and that my employment may be terminated with or without cause, and without notice, at any time, at my option or the company's, unless specifically provided otherwise in a written employment contract. I further understand that no company employee or representative has the authority to enter into a contract regarding duration or terms and conditions of employment other than an officer or official of the company, and then only by means of a signed, written document.

Date

captcha