Position(s) applied for - Required

Date of application - Required

Name - Required

Mailing Address - Required

Telephone - Required

Cell Phone Number - Required

E-mail Address - Required

Referral Source

If you are under 18, and it is required, can you furnish a work permit?

Yes

No

If no, please explain

Have you ever been employed here before?

Yes

No

If yes, give dates and positions

Are you legally eligible for employment in this country?

Yes

No

Date available for work - Required

Ending Date? - Required

What is your desired salary range? - Required

Type of employment desired

Full Time

Part Time

Year round

Seasonal

Driver's license number if driving may be required in position for which you are applying

State

Number

Employment History Starting with your most recent employer, provide the following information.

Employer #1

Telephone #

Street Address

City/State

Dates Employed From

TO

Starting Job Title

Final Job Title

Immediate supervisor and title (for most recent position held)

Why did you leave?

May we contact for reference?

Yes

No

Later

Summarize the type of work performed and job responsibilities

What did you like the most about your position?

What were the things you liked least about the position?

Employer #2

Telephone #

Street Address

City/State

Dates Employed From

TO

Starting Job Title

Final Job Title

Immediate supervisor and title (for most recent position held)

Why did you leave?

May we contact for reference?

Yes

No

Later

Summarize the type of work performed and job responsibilities

What did you like the most about your position?

What were the things you liked least about the position?

Employer #3

Telephone #

Street Address

City/State

Dates Employed From

TO

Starting Job Title

Final Job Title

Immediate supervisor and title (for most recent position held)

Why did you leave?

May we contact for reference?

Yes

No

Later

Summarize the type of work performed and job responsibilities

What did you like the most about your position?

What were the things you liked least about the position?

Skills and Qualifications

Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying.

Please also list all computer skills

Educational Background Starting with your most recent school attended, provide the following information.

School #1

City/State

Years Completed

GPA/Class Rank

Major/Minor

School #2

City/State

Years Completed

GPA/Class Rank

Major/Minor

School #3

City/State

Years Completed

GPA/Class Rank

Major/Minor

References List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

Reference #1 Name

Title

Relationship to You

Telephone

Number of Years Known

Reference #2 Name

Title

Relationship to You

Telephone

Number of Years Known

Reference #3 Name

Title

Relationship to You

Telephone

Number of Years Known

Applicant Statement

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 90 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 CHECK UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Applicant's Name

Applicant Date

AN EQUAL OPPORTUNITY EMPLOYER

Application