EMPLOYMENT APPLICATION

I. PERSONAL INFORMATION

Last Name		First Name
Middle Name		Date
Street Address
City		State
Zip		DOB
Phone #		Email Address

If hired, would you have reliable transportation? Yes No

Have you ever worked under a different name? Yes No If Yes, name:

Do you know anyone who is working here? Yes No If Yes, name and relationship:

Have you ever worked for the Company? Yes No If Yes, when and position held:

Can you meet attendance requirements? Yes No If No, why not:

II. EMPLOYMENT INTERESTS

Position Desired: Date Available: Salary Desired:

Hourly Wage Annual Salary

Type of Employment Desired: Regular Full-Time Temporary Part-Time

Would you be willing to work overtime? Yes No Hours per week requested?

III. EDUCATION INFORMATION

School Level	Name and Location of School	Did you graduate?	Certificate or Degree Earned
High School		Y N
College/University		Y N
Post-Graduate		Y N
Business/Trade Technical		Y N

IV. REFERENCES

Name	Title and Company	Phone Number	Your Work Relationship with this Person

V. EMPLOYMENT INFORMATION (Begin with current or most recent employer)

Employer 1
Company Name:
Phone: From: To:
Street Address:
City/State/Zip:
Starting Pay: $ Ending Pay: $
Job Title:
Duties:

Reason for leaving:

Supervisor Name: May we contact? Yes No

Employer 2
Company Name:
Phone: From: To:
Street Address:
City/State/Zip:
Starting Pay: $ Ending Pay: $
Job Title:
Duties:

Reason for leaving:

Supervisor Name: May we contact? Yes No

Employer 3
Company Name & Website:
Phone: From: To:
Street Address:
City/State/Zip:
Starting Pay: $ Ending Pay: $
Job Title:
Duties:

Reason for leaving:

Supervisor Name: May we contact? Yes No

Please account for any time you were not employed in the last 10 years, or since leaving school.
Time period: Reason for unemployment:

VI. ACKNOWLEDGMENT

Please read carefully, initial each paragraph, and sign below.

Initial: I hereby certify that I have not withheld or misstated any material facts that might adversely affect my application for employment and that the answers given by me are true and correct. I further certify that I have personally completed this application. I understand that any omission or misstatement may be grounds for rejection or termination.

Initial: I hereby authorize the Company to investigate my references, work record, education, and other matters related to my suitability for employment and authorize former employers to disclose relevant information.

Initial: I understand that some positions require criminal background checks and that a criminal conviction is not an automatic disqualification for hire.

Applicant’s Signature:
Date: