Please complete all sections of this application. If you do not recall a specific detail, indicate it accordingly.
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Full name
Last*
First*
M.I.*
Date*
Address
Street Address*
Apartment/Unit #*
City*
State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
ZIP Code*
Phone*
E-mail Address*
Date Available*
Social Security No.*
Desired Salary $*
Position Applied for*
If hired, when could you start?*
If under 18 years of age, can you provide a work permit, if hired?* YesNo
Have you ever been convicted of a crime other than a traffic violation?* YesNo
Have you ever been convicted of a felony?* YesNo
If “YES”, please explain: (Note: Conviction is not an automatic bar to employment. Each case will be considered on its own merits):
Please indicate the days and times you are available to work.
Monday*
Tuesday*
Wednesday*
Thursday*
Friday*
Saturday*
Sunday*
Specialized technical training/skills (i.e. equipment operation, machines used, etc.) including bilingual ability (If relevant to the position for which you are applying):
Are you able to perform the essential functions of the position you are applying for, with or without reasonable accommodation? YesNo
If no, please describe the functions that cannot be performed:
Note: We comply with the Americans with Disabilities Act (ADA) and consider reasonable accommodations that may be necessary for eligible applicants/employees to perform essential functions. Employment may be subject to passing a medical examination and skill or agility tests.
Employer No. 1:
Company*
Address*
Supervisor*
Job Title*
Starting Salary $*
Ending Salary $*
Responsibilities*
From*
To
Reason for Leaving*
May we contact your previous supervisor for a reference?* YesNo
Employer No. 2: Company*
Employer No. 3: Company*
High School
From
Did you graduate? YesNo
College
Degree
Other
Please list two professional references (not relatives).
Full Name*
Relationship*
Position & Company*
Full Name
Relationship
Position & Company
Phone
Equal Opportunity Employer Statement
We are committed to providing equal employment opportunities. We do not discriminate based on race, religion, color, national origin, gender, age, disability, veteran status, or any other protected category under applicable federal, state, or local law.
Background Investigation
I understand that my employment is contingent upon the successful completion of a background check, which may include employment history, education verification, credit history, DMV records, and criminal record checks. I authorize all persons and organizations with relevant information to release such details.
Employment-at-Will Agreement
I understand that my employment is "at-will" and may be terminated by either myself or the company at any time, with or without cause, and without prior notice. No oral or implied agreement can alter this condition.
Drug-Free Workplace
I acknowledge that the company reserves the right to conduct drug testing as a condition of employment and at any time during my employment. Possession, use, or influence of illegal drugs on the job will result in immediate termination.
Other Employment Terms
I understand that all employment offers are conditional and may be subject to further verification, background investigations, and required testing.
Applicant Certification & Acknowledgment
I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in my application or interview may result in the rejection of my application or, if hired, in my immediate termination. I authorize the Company to verify any of the statements provided in this application unless I have indicated otherwise.
I understand that falsification or omission of any material information in this application, providing misleading information, or failing to pass any required physical examination (if applicable) may be grounds for immediate termination of employment. If hired, I agree to abide by all company policies and procedures.
I hereby acknowledge that my employment is "at-will," meaning that I may resign at any time and that the Company may terminate my employment at any time, with or without cause, and with or without notice. I understand that no oral assurances of continued employment, whether expressed or implied, shall alter this relationship unless specifically acknowledged in writing by the Company’s President. I further acknowledge that this application does not constitute an employment contract, express or implied.
* I have read and understand the above terms and agreements.
