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Employment Application

You will be considered for all positions without regard to race, color, religion, weight, height, sex, national origin, marital status, veteran status, the presence of non-job related medical condition, handicap, or any other protected status required by law.

Position you are applying for:
Location you are applying for:
You were referred by:
Relative Advertisment
Friend Employment Agency
Walk-in Other
Personal Information:
Name:
Address:
City:
State:
Zip Code:
Home Telephone:
Email Address:

Are you under 18?
Yes No
If yes, can you provide a work permit?
Yes No

Have you ever applied
with our company?

 
Yes No
If yes, date:
Have you ever been employed by our company?
Yes No
If yes, date:
Are you employed now?
Yes No
If yes, date:
May we contact your present and previous employers?
Yes No
Desired salary:
What date would you be available to start work?
Are you available to work:
Full-time Part-time Shift-work Temporary
Can you travel if required?
Yes No
Do you have a valid drivers license?
Yes No

Is there any Visa or immigration status that would prevent you from becoming employed in this country?

 

 

( Proof of citizenship or immigration status will be required upon employment.)
Yes No
If yes, please explain:
Have you been convicted of a felony?
Yes No
Are you a veteran of the U.S. Military Service?
Yes No
If yes, what branch:
Which languages do you speak, read and/or write, if any?
Please indicate if fluent, good, or fair:

Education:

Type of school
Name of School/Location
Years attended
Degree granted and when graduated
Major
High School
College
College
Post graduate, trade, correspondence

Professional Associations:

List professional, trade, business or civic activities and offices held. ( You may exclude membership which would reveal sex, race, religion, national origin, age, ancestry, or handicap or other protected status.)

Employment History:

( If records are under a different name, please provide name for reference purposes, starting with present or last employer. List all employment including part-time or temporary positions. Use additional sheets, if necessary.)

Name of employer:
Address:
City:
State:
Zip Code:
Employer telephone number:
Dates employed:
From: To:
Name of Supervisor:
Beginning Salary:
Ending Salary:
Title and duties at beginning of employment:
Title and duties at end of employment:
Reason for leaving:
 
 
Name of employer:
Address:
City:
State:
Zip Code:
Employer telephone number:
Dates employed:
From: To:
Name of Supervisor:
Beginning Salary:
Ending Salary:
Title and duties at beginning of employment:
Title and duties at end of employment:
Reason for leaving:
  
 
Name of employer:
Address:
City:
State:
Zip Code:
Employer telephone number:
Dates employed:
From: To:
Name of Supervisor:
Beginning Salary:
Ending Salary:
Title and duties at beginning of employment:
Title and duties at end of employment:
Reason for leaving:
 
 
Name of employer:
Address:
City:
State:
Zip Code:
Employer telephone number:
Dates employed:
From: To:
Name of Supervisor:
Beginning Salary:
Ending Salary:
Title and duties at beginning of employment:
Title and duties at end of employment:
Reason for leaving:

 

 References:

( Give the names, addresses, and phone numbers of three references not related to you.)

Reference 1:

Name:
Occupation:
Address:
City:
State:
Zip Code:
Telephone:

Reference 2:

Name:
Occupation:
Address:
City:
State:
Zip Code:
Telephone:

Reference 3:

Name:
Occupation:
Address:
City:
State:
Zip Code:
Telephone:

You are not required to disclose information about physical or mental limitations that you believe will not interfere with your capability to do the job. However, if you want the employer to consider special arrangements to accomodate a physical or mental impairment, you may identify that impairment in the space provided and suggest the kind of acccomadation that you believe would be appropriate.  

 

I UNDERSTAND THAT IF HIRED, MY EMPLOYMENT RELATIONSHIP WILL BE AT-WILL, AND THAT EITHER I OR DOUGLAS J, MAY TERMINATE THE EMPLOYMENT RELATIONSHIP WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE. I FURTHER UNDERSTAND THAT THIS EMPLOYMENT RELATIONSHIP MAY NOT BE MODIFIED BY VERBAL STATEMENTS, CUSTOMS, PRACTICES, OR WRITTEN DOCUMENTS UNLESS SUCH MODIFICATION IS IN WRITING AND SIGNED BY AN AUTHORIZED AGENT OF DOUGLAS J.