Application for Employment Step 1 of 3 33% An Equal Opportunity Employer We do not discriminate on the basis of race, color, religion, national origin, sex age or disability. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. Use blank paper if you do not have enough room on this form. Please print, except for signature on back of application. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information.Personal InformationJob applied for:*Today's date:* MM slash DD slash YYYY Are you seeking:* Full time Part time Temporary When could you start work?* MM slash DD slash YYYY Name* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are you 18 years of age or older?*If you are hired, you may be required to submit proof of age. Yes No If hired, can you furnish proof you are eligible to work in the U.S.?* Yes No Have you ever applied here before?* Yes No When did you apply before?Were you ever employed here?* Yes No When were you employed here before?Have you ever been convicted of any law violation?*Include any plea of "guilty" or "no contest." Exclude minor traffic violations. Yes No Please give details.EducationPlease list name and address of schools, number of years completed, and diploma/degree/certificate received.High School or GEDCollege or UniversityPost GraduateVocational or Technical SkillsWhat skills or additional training do you have that are related to the job for which you are applying?*What machines or equipment can you operate that are related to the job for which you are applying?*How many days of work have you missed during the past year?*Exclude absences due to disability or those covered by the Family and Medical and Leave Act.Do you have a valid driver's license?* Yes No Driver's License NumberClass of LicenseHave you ever had your driver's license suspended or revoked in the past 3 years?* Yes No Please give details.OtherList professional, trade, business or civic activities and offices held.Exclude labor organizations and memberships that reveal race, color, religion, national origin, sex, age, disability or other protected status.Work HistoryList names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and business references. NOTE: A job offer may be contingent upon acceptable references from current and former employers.Employer 1Employer 1 Name*Employer 1 Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employer 1 Phone*Employer 1 Supervisor*Employer 1 Employment period (begin/end)*Employer 1 Title/duties*Employer 1 Reason for leaving*Employer 2Employer 2 Name*Employer 2 Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employer 2 Phone*Employer 2 Supervisor*Employer 2 Employment period (begin/end)*Employer 2 Title/duties*Employer 2 Reason for leaving*Employer 3Employer 3 Name*Employer 3 Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employer 3 Phone*Employer 3 Supervisor*Employer 3 Employment period (begin/end)*Employer 3 Title/duties*Employer 3 Reason for leaving*Employer 4Employer 4 Name*Employer 4 Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employer 4 Phone*Employer 4 Supervisor*Employer 4 Employment period (begin/end)*Employer 4 Title/duties*Employer 4 Reason for leaving* ReferencesAre you presently employed?* Yes No May we contact your employer? Yes No Current Employer NameCurrent Employer PhoneHave you ever been fired from a job or asked to resign?* Yes No Give three references, not relatives or former employers.Reference 1 Name* First Last Reference 1 Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Reference 1 Phone*Reference 2 Name* First Last Reference 2 Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Reference 2 Phone*Reference 3 Name* First Last Reference 3 Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Reference 3 Phone*AffadavitPlease read each statement carefully before submitting. I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand I will be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment. I understand that this application or subsequent employment does not create a contract of employment nor guarantee employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without cause and without notice. I have read, understand, and by submitting my application consent to these statements. Application for Employment Non-Discrimination Notice Notice of Privacy Practices
