EMPLOYMENT APPLICATION

CONTACT INFORMATION

First Name*

Middle Name

Last Name*

Email*

Date*

Street Address*

Apt#

City*

State*

Zip Code*

Day Phone

Evening Phone

EMPLOYMENT DESIRED

Position applying for:*

Checkboxes

Full time work

Part time work

Temp work

Hours

If temporary, what period of time are you applying for? From:

If temporary, what period of time are you applying for? To:

Available for weekends?

Yes

No

Available for overtime?

Yes

No

If hired, what date can you start?

Salary desired:

PERSONAL INFORMATION

Have you ever applied to this company before?*

Yes

No

If yes, when?

Do you have any relatives working for this company?

Yes

No

If yes, state name and relationship

Why are you applying for work at this company?

If hired, would you have a reliable means of transportation to and from work?

Yes

No

Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)

Yes

No

If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?

Yes

No

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?

Yes

No

If no, describe the functions that cannot be performed

Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (Convictions for marijuana-related offenses that are more than two years old need not be listed.)

Yes

No

If yes, state nature of the crime(s), when and where convicted, and disposition of the case:

Are you currently employed?

Yes

No

If so, may we contact your current employer?

Yes

No

EDUCATION, TRAINING AND EXPERIENCE

High School:

Address:

Graduate?

Yes

No

Years attended?

Diploma?

Yes

No

College:

Address:

Graduate?

Yes

No

Years attended?

Degree?

Yes

No

Vocational/Trade School:

Address:

Graduate?

Yes

No

Years attended?

Degree?

Yes

No

Many of our customers do not speak English. Do you speak, write or understand any foreign languages?

Yes

No

If yes, which language(s)?

Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at this company?

Yes

No

If yes, please explain:

Answer the following questions if you are applying for a professional position: Are you licensed/certified for the job for which you are applying?

Yes

No

Name of license/certification:

Issuing State:

License #:

Has your license/certification ever been revoked or suspended?

Yes

No

If yes, state reason(s):

Date of reinstatement

date of revocation or suspension

EMPLOYMENT HISTORY

Employer:

Type of Business:

Dates Employed:

Address:

Phone:

Supervisor’s Name:

Your Position and Duties:

Reason for Leaving:

May we contact this employer for a reference?

Yes

No

Employer:

Type of Business:

Dates Employed:

Address:

Phone:

Supervisor’s Name:

Your Position and Duties:

Reason for Leaving:

May we contact this employer for a reference?

Yes

No

Employer:

Type of Business:

Dates Employed:

Address:

Phone:

Supervisor’s Name:

Your Position and Duties:

Reason for Leaving:

May we contact this employer for a reference?

Yes

No

Employer:

Type of Business:

Dates Employed:

Address:

Phone:

Supervisor’s Name:

Your Position and Duties:

Reason for Leaving:

May we contact this employer for a reference?

Yes

No

MILITARY SERVICE

Have you obtained any special skills or abilities as the result of service in the military?

Yes

No

If so, describe:

REFERENCES

List three persons not related to you who have knowledge of your performance over the last few years

First Name:

Last Name:

Relationship:

Address:

Phone:

Years Acquainted:

Occupation:

First Name:

Last Name:

Relationship:

Address:

Phone:

Years Acquainted:

Occupation:

First Name:

Last Name:

Relationship:

Address:

Phone:

Years Acquainted:

Occupation:

Please Read Carefully, and Sign Below

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I hereby authorize this company and Employer’s Guardian to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the Company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I hereby authorize this company and Employer’s Guardian to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the release of all information obtained by Employer’s Guardian, LLC. while performing Human Resources, Payroll, Workers’ Compensation Administration, OSHA and other employer related duties for other organizations where the applicant may have applied for employment, interviewed for a job opportunity or been employed over the past five years. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company's designated representative.

Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien or outstanding judgment) be conducted by internal personnel employed by the Company, I am entitled to copies of any such public records obtained by the Company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.

I waive receipt of a copy of any public record described in the paragraph above

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Date

* Applications are considered active for employment consideration for sixty (60) days. If you wish to be considered for any openings after sixty (60) days, please submit an updated application.

CONTACT INFORMATION

EMPLOYMENT DESIRED

PERSONAL INFORMATION

EDUCATION, TRAINING AND EXPERIENCE

EMPLOYMENT HISTORY

MILITARY SERVICE

REFERENCES

Please Read Carefully, and Sign Below

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