Employment Application Form

Personal Information

Last Name *

First Name *

Middle Initial

Social Security #*

Address & Contact

Street Address*

City*

State*

Zip Code*

Phone Number*

Work Eligibility

If hired, can you provide evidence of legal eligibility to work in the U.S.?*

Yes

Position & Compensation

Position Desired*

Wage/Salary Desired*

Employment Type

Full Time

Part Time

Criminal History

Have you ever been convicted of a felony or a misdemeanor involving a violent act, weapon use/possession, or dishonesty (or have a pending case)?*

Yes

Work Start Date & Age

Date you can begin work*

Are you 18 years of age or older?*

Yes

Education

Name of High School Attended

City & State

Graduate?

Yes

GED?

Yes

Name of College or Technical School

City & State

Graduate?

Yes

Degree

Major

Are you presently enrolled in school?

Yes

Job-Related Skills & Accomplishments

List any job-related skills, accomplishments, or military service

Work Availability

For each day, indicate your available time (if applicable):*

Total hours per week you are available

Do you have any special requests or needs for your work schedule?

References (Provide Three)

Reference 1

Reference 2

Reference 3

Employment History

Employer Information

Name of Employer*

Job Title*

Duties

Address*

From*

To*

City, State, Zip Code*

Starting Pay

Ending Pay

Hourly Pay/Salary

Supervisor*

Telephone*

Reason for Leaving

Certification

I certify that all of the information provided in this employment application is true and complete to the best of my knowledge. I authorize investigation of all statements contained herein, including a criminal background and credit history check. I understand that any false or incomplete information may disqualify me from employment or result in immediate discharge if discovered later.

I understand that unless otherwise defined by applicable law or written agreement, any employment relationship is “at will” and may be terminated by either party at any time.

I authorize the investigation of any or all statements provided and release all persons and organizations from liability.

Signature*

Date*

Employment Application