Application For Employment

PERSONAL INFORMATION
NAME (LAST NAME FIRST) *:
PRESENT ADDRESS
APT.NO.
CITY
STATE
ZIP
PHONE # *
CELL PHONE #
ARE YOU 18 YEARS
OR OLDER?
YES    NO
ARE YOU LEGALLY
AUTHORIZED
TO WORK IN US?
YES    NO
EMAIL *
EMERGENCY CONTACT
NAME     PHONE
DESIRED EMPLOYMENT
POSITION
DATE YOU CAN START
SALARY DESIRED
ARE YOU EMPLOYED NOW?
YES    NO
IF SO MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?
YES    NO
EVER APPLIED TO THIS COMPANY BEFORE?
YES    NO
WHERE?
WHEN?
REASON FOR LEAVING
NAME OF LAST SUPERVISOR AT THIS COMPANY
HOW DID YOU FIND OUT ABOUT THIS POSITION?
 EMPLOYMENT AGENCY              NEWSPAPER ADVERTISING            FRIEND       ONLINE AD
 STATE EMPLOYMENT OFFICE    COLLEGE PLACEMENT SERVICE     WALK IN    OTHER
EDUCATION
SCHOOL LEVEL NAME AND LOCATION
OF SCHOOL
NO. OF YEARS
ATTENDED
DID YOU GRADUATE SUBJECTS STUDIED
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS OR
CORRESPONDENCE
SCHOOL
GENERAL
SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK
SPECIAL TRAINING, CERTIFICATES, LICENSES
SPECIAL SKILLS, FOREIGN LANGUAGES,ETC
FORMER EMPLOYERS
LIST BELOW LAST THREE EMPLOYERS, STARTING WITH THE MOST RECENT
NAME OF PRESENT OR LAST EMPLOYER
ADDRESS
CITY
STATE
ZIP
STARTING DATE
LEAVING DATE
JOB TITLE
WEEKLY STARTING SALARY
WEEKLY FINAL
SALARY
MAY WE CONTACT YOUR SUPERVISOR?
YES    NO
NAME OF SUPERVISOR
TITLE
PHONE
DESCRIPTION OF WORK
REASON FOR LEAVING
NAME OF PRESENT OR LAST EMPLOYER
ADDRESS
CITY
STATE
ZIP
STARTING DATE
LEAVING DATE
JOB TITLE
WEEKLY STARTING SALARY
WEEKLY FINAL
SALARY
MAY WE CONTACT YOUR SUPERVISOR?
YES    NO
NAME OF SUPERVISOR
TITLE
PHONE
DESCRIPTION OF WORK
REASON FOR LEAVING
NAME OF PRESENT OR LAST EMPLOYER
ADDRESS
CITY
STATE
ZIP
STARTING DATE
LEAVING DATE
JOB TITLE
WEEKLY STARTING SALARY
WEEKLY FINAL
SALARY
MAY WE CONTACT YOUR SUPERVISOR?
YES    NO
NAME OF SUPERVISOR
TITLE
PHONE
DESCRIPTION OF WORK
REASON FOR LEAVING
REFERENCES LIST PROFESSIONAL REFERENCES WHOM WE MAY CONTACT
NAME ADDRESS BUSINESS PHONE NUMBER
1
2
3
4
SERVICE RECORD
HAVE YOU EVER SERVED IN THE U.S. ARMY FORCES?
YES    NO
BRANCH OF SCIENCE
DISCHARGE DATE
RANK
HAVE YOU EVER BEEN CONVICTED OF ,PLEAD GUILTY/NO CONTEST TO, OR HAD A SUSPENDED
IMPOSITION OF SENTENCE FOR ANY OFFENSE(OTHER THAN A MINOR TRAFFIC VIOLATION)?
YES    NO
IF YES, EXPLAIN

(A CONVICTIONAL RECORD WILL NOT NECESSARILY EXCLUDE YOU FROM CONSIDERATION. THIS INFORMATION WILL BE USED ONLY FOR JOB-RELATED PURPOSES AND ONLY TO THE EXTENT PERMITTED BY LAW.)
AUTHORIZATION
I WILL CERTIFY THAT THE FACTS CONTAINED IN THE APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL
I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION.
I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR SPECIFIED PERIOD OF TIME, OR TO MAKE AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE
THIS WAIVER DOES NOT PERMIT THE RELEASE OR USE OF DISABILITY-RELATED OR MEDICAL INFORMATION IN A MANNER PROHIBITED BY THE AMERICANS WITH DISABILITIES ACT (ADA) AND NO OTHER RELEVANT FEDERAL AND STATE LAWS.
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