EMPLOYMENT APPLICATION

Last Name                             First Name                         Middle Initial

Social Security Number:

Street Address                      City/State                          Zip Code

Phone Number:

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

Position Desired:

Wage/Salary Desired:

Full Time?
Part Time?

Date you can begin work?

Are you 18 years of age or older?

If under 18 years of age, you will be required to submit a birth certificate or work certificate as required by state or federal law.

Name of high school attended:

City & State

Graduate?

GED?

Name of college or technical school:

City & State

Graduate?

Degree?

Major:

Are you presently enrolled in school?

If yes, give name & address of school and expected degree date:

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

- Your Availability For Work -

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

From:

To:

Total hours per week you are available to work:

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

- Give Three References That Are Not Former Employers Who We May Contact -

Name and Occupation

How do you know them, and for how long?

Phone Number

Name of Employer:

Job Title:
Duties:

Address:

Dates of Employment:
From:                                       To:

City, State, Zip Code

Hourly pay or salary:
Starting pay:                             Ending pay:

Supervisor: 
Telephone:

Reason for Leaving:

Name of Employer:

Job Title:
Duties:

Address:

Dates of Employment:
From:                                       To:

City, State, Zip Code

Hourly pay or salary:
Starting pay:                             Ending pay:

Supervisor: 
Telephone:

Reason for Leaving:

Name of Employer:

Job Title:
Duties:

Address:

Dates of Employment:
From:                                       To:

City, State, Zip Code

Hourly pay or salary:
Starting pay:                             Ending pay:

Supervisor: 
Telephone:

Reason for Leaving:

 CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM

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

I understand and acknowledge that unless otherwise defined by applicable law or written agreement with [Company name], any employment relationship with the [Company name] is considered “employment at will.”  This means the Employee may resign at any time and the Employer may discharge the Employee at any time, with or without cause, and with or without advance notice.

I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer, past employers, and other organizations to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision.  I release such persons and organizations from any legal liability in making such statements.

I have read, understand, and agree to the above statements. 

Signature:

Date: