Employment Application

Name*

First Last

Present Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long have you been at your present address?*

Phone*

Location Applying for*

Position Applying For*

Referred By

Salary Desired*

Can you work nights?*

Yes
No

How many hours can you work weekly?*

Date you can start*

Employment Desired*

Full-Time Only
Part-Time Only
Full-Time or Part-Time

Availability

Days/Hours you CAN work

No Preference	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday

Education

High School*

School Name	School Type	Location	Number of years completed

College

College Name	College Type	Location	Number of years completed	Major & Degree

Criminal History

Have you ever been convicted of a crime?*

Yes
No

If yes, explain the number of conviction(s), nature of offense(s) leading to cconviction(s), how recently such offenses(s) was/were committed, sentence(s) imposed, and types(s) of rehabilitation.*

What is your means of transportation to work?*

Military History

Have you ever enlisted in the Armed Forces?*

Yes
No

Are you now a member of the National Guard?*

Yes
No

Enlistment details*

Specialty	Date Entered	Discharge Date

Work Experience

Please list your work experience for ht past five years beginning with your most recent job held. If you were self-employed, give the firm name.

Employment History*

Name of Employer	Employment Dates	Name of Supervisor	Job Title	City, State, Zip	Telephone Number	Reason for Leaving	List jobs and duties

Authorization*

I certify that the facts contained in this 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 any 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 company had any authority to enter into any agreement for employment for any specified period of time, or to make any 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 other relevant federal and state laws.