Employment Opportunities

Application for Employment

Name
Last name*:			First name*:
Middle name:			Maiden name:
Present Address
Street Address*:
City*:			Zip*:
State*:
Telephone
Primary*:			Secondary:
Email Address*:
If under 18, please list age:
Are you legally able to work in U.S.?	YES		NO
Position applied for*:
Salary Desired:
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Days/hours available to work
No Preference:			Monday:
Tuesday:			Wednesday:
Thursday:			Friday:
Saturday:			Sunday:
How many hours can you work weekly?*
Employment desired*:	FULL-TIME ONLY		PART-TIME ONLY	FULL- OR PART-TIME
When are you available for work?*
Do you have any commitments to another employer (e.g., proprietary information/non-compete agreement, etc.)?*
How were you referred to us?*
May we contact your current employer?*	YES		NO
When may we contact your current employer?*
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Employment History
Please provide all employment information on your past four employers starting with the most recent:

Employer
Employer*:			Position Held*:
Address*:			Telephone*:
Dates employed from*:			to*:
Job summary*:
Reason for leaving*:
Employer
Employer*:			Position Held*:
Address*:			Telephone*:
Dates employed from*:			to*:
Job summary*:
Reason for leaving*:
Employer
Employer:			Position Held:
Address:			Telephone:
Dates employed from:			to:
Job summary:
Reason for leaving:
Employer
Employer:			Position Held:
Address:			Telephone:
Dates employed from:			to:
Job summary:
Reason for leaving:
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Knowledge, Skills, and Qualifications Summarize any job-related training, skills, licenses, certificates, experiences and/or other qualifications that would especially fit you for work with our organization:

Educational History
Type of School	Name of School	Location (Complete mailing address)	Number of Years Completed	Major & Degree
High School*	Name of School*	Location (Complete mailing address)*	Number of Years Completed*	Major & Degree*
College	Name of School	Location (Complete mailing address)	Number of Years Completed	Major & Degree
Business or Trade School	Name of School	Location (Complete mailing address)	Number of Years Completed	Major & Degree
Professional School	Name of School	Location (Complete mailing address)	Number of Years Completed	Major & Degree

Account for any lapse of time not covered in your employment or educational record:
Have you ever been terminated, asked to resign or left a job without notice?*			NO	YES
Please explain*:	---
Have you ever been convicted of a felony or misdemeanor?*			NO	YES
Please explain*:	---
Professional References List required references: name, telephone number, company name and years known (do not include relatives)
1.)*:
2.)*:
3.)*:
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Have you ever been in the United States Armed Forces?*	YES		NO
If yes, what branch?
Rank at discharge:
Dates of duty from:			to:
Duties and training:
Uploads
Upload Additional Files / Resumes
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Voluntary Self Identification Record

The Equal Employment Opportunity Commission (EEOC) requires all private employers with 100 or more employees as well as federal contractors and first-tier subcontractors with 50 or more employees AND contracts of at least $50,000 to invite applicants to self-identify gender and race and complete an EEO-1 report each year. Completion of this form is voluntary and will not affect your opportunity for employment, or the terms or conditions of your employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources department.

VOLUNTARY SURVEY

Government agencies at times require periodic reports on sex and other protected status of applicants. This data is for analysis and possible affirmative action only. Please check one box in each column. SUBMISSION OF THE FOLLOWING INFORMATION IS VOLUNTARY.

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REPRESENTATIONS, UNDERSTANDINGS AND AGREEMENTS OF APPLICANT

The facts set forth in my application for employment and in any resume or other documents provided for consideration in the application process are true and complete, without consequential omissions of any kind whatsoever. I understand that falsification of statements, answers or omission made by me in this application, in any other document provided for consideration in the application process and in any interview shall be considered sufficient cause for immediate dismissal if I am employed.

I hereby give the Company the right to verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I authorize the persons, or entities named on this application form, and any other contacts the Company so discovers during the performance of my background and reference checks, (collectively “Contacts”) to give any information regarding me whether the information is positive or negative, whether or not it is in their records, and I release from all liability all persons and entities supplying such information. I indemnify the Company against any liability which might result from making such investigation.

I further release and hold harmless both the Contacts and the Company from any and all liability that may potentially result from the release and/or use of such information. I understand that any information released to the Company by a Contact will be held in strictest confidence, that it will be viewed only by those involved in the hiring decision, and that neither I nor anyone else not so involved will have the right to see the information. This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign.

I understand that in connection with the routine process of my employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company Inc. will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I understand that it is the policy of the Company not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the Americans with Disabilities Act (ADA). I also understand that, if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization in accordance with the Immigration Reform and Control Act of 1986 within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the Company and myself, for either employment of for the providing or any benefits. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Company unless made in writing.

I also understand that (1) the Company may have a drug and alcohol policy that may provide for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

If accepted by the Company for employment, I hereby agree to abide by the directions, rules and policies of my employer whether or not in writing as they may be changed from time to time without notice. I agree that only written representations and promises signed by both myself and an officer of the Company will be enforceable and I understand that my employment may be terminated at will by either party. I understand that no supervisor at the Company has the authority to change this employment at-will status.

I understand that my application will be considered current for a period of up to ninety days. If I wish to be considered for employment at this company after that time, I understand that I must re-apply.I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Date*:			I hereby agree to all of the above terms and conditions.*
Signature*:	Sign above Clear Signature Field
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