Employment Application Name * First Name Last Name Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Type of Employment Desired Full-Time Part-Time Temporary Referral Source Driver's License Number Salary Requirements Date Available to Start * MM DD YYYY Are you below the age of 18? * Yes No Have you previously worked for this company? * Yes No Are you legally allowed to work in the United States? * Yes No In the past 7 years, have you ever pleaded guilty or no contest or been convicted of a crime involving violence, theft of property or identity or drugs? * Answering yes does not constitute an automatic rejection for employment. Yes No Name and Location of High School * Name and Location of College Trade, Business, or Correspondence School Character References * Previous Employment (Job One) Start Date MM DD YYYY End Date MM DD YYYY Position(s) held Company Name Company Address Address 1 Address 2 City State/Province Zip/Postal Code Country Company Phone (###) ### #### Company Supervisor/Title Responsibilities Starting salary and title Ending salary and title Reason for leaving May we contact this employer for a reference? Yes No Previous Employment (Job Two) Start Date MM DD YYYY End Date MM DD YYYY Position(s) held Company Name Company Address Address 1 Address 2 City State/Province Zip/Postal Code Country Company Phone (###) ### #### Company Supervisor/Title Responsibilities Starting salary and title Ending salary and title Reason for leaving May we contact this employer for a reference? Yes No Previous Employment (Job Three) Start Date MM DD YYYY End Date MM DD YYYY Position(s) held Company Name Company Address Address 1 Address 2 City State/Province Zip/Postal Code Country Company Phone (###) ### #### Company Supervisor/Title Responsibilities Starting salary and title Ending salary and title Reason for leaving May we contact this employer for a reference? Yes No Skills and Qualifications Employment Application Agreement * I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. I Agree Signature of Applicant: * * First Name Last Name Thank you!
