Employment Application

THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT  but merely is intended to evaluate suitability for employment. It is the policy of the company to provide equal employment to all qualified persons without discrimination on the basis of sex, race, color, religion, age, national origin, citizenship, disability, veteran status, or any other status protected under local, state or federal law. It is also the policy of the company to have the option of conducting pre-employment screening before a job offer is made. If a job offer is made, employment may be contingent upon the successful completion of a pre-employment drug screening and/or medical examination. This application will remain active for 3 years.

Personal Information

First Name:		Middle Name:		Last Name:
Home Phone:		Work Phone:		Cell Phone:
Email Address:

Addresses

	Street:	City:	State:	Zip Code:	Since (Mo/Yr):	To (Mo/Yr):
Current Address:
Prior Address:
Prior Address:

Employment Information

Position Applied For:

Date You Can Start:

Desired Salary: $

Do You Prefer:

Full-TimePart-Time

Can you work:

Weekends  Evenings

Available:

M Tu W Th F Sa Su

Not Available:

	Please answer all of the following questions.
1.	Are you at least 18 years of age and legally eligible to work for our company in the United States?	No Yes
2.	Have you worked for this business before?	No Yes
	If yes, please provide dates and locations.
3.	Have you received a description of the job or been made aware of the essential functions of the job for which you are applying?	No Yes
4.	Do you understand the job requirements?	No Yes
	If no, please explain.
5.	Are you on layoff and subject to recall?	No Yes
6.	Are you currently bound by a noncompetition, confidentiality or trade secret agreement?	No Yes
	If yes, please explain...
7.	Have you ever been discharged or asked to resign from a job?	No Yes
	If yes, please explain...
8.	Have you ever been convicted of or pled guilty to a felony or crime other than a minor traffic citation?	No Yes
	If yes, please explain...

Employment History

	May we contact your present employer?			No Yes
	Please list below your last four employers beginning with the most recent:
	Most Recent Employer	Prior Employer (1)	Prior Employer (2)	Prior Employer (3)
Employer:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Pay Upon Leaving:
Supervisor:
Duties:
Reason For Leaving:

Job-related Skills

	Please answer the following questions if the position you are applying for requires driving a motor vehicle:
1.	Do you have a valid driver's license?	No Yes
	If yes, Driver's License Number: Date of Issue:
2.	Have you been convicted of or pled guilty to any traffic-related offense within the past five years?	No Yes
3.	Have you had your driver's license suspended or revoked or had your driving privileges modified by a court of law?	No Yes
4.	Please list all states from which you hold or held a driver's license:
	Please use this space to list any special skills you may have that relate to the position applied for:
	Please list any professional licenses, designations, certifications, etc. that may relate to the position applied for. Include date granted, name of organization, and any other relevant information.

References

	Reference (1)	Reference (2)	Reference (3)	Reference (4)
Name:
Address:
Telephone:
Relationship:
Years Acquainted:

Resume (Text Version)

Copy and Paste a text version of your resume here.

Upload File

Attach a file to your application submission

CERTIFICATION AGREEMENT

1.	I authorize the investigation of all statements contained in this application and release from all liability any persons or employers supplying such information, and I also release the company from all liability that might result from making the investigation.
2.	I certify that the facts and information set forth in this application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts on this application (or on any required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.
3.	I agree, if I am offered and accept a position, to conform to all existing and future Company rules and regulations and I understand that the Company reserves the right to change wages, hours and working conditions as deemed necessary. I ALSO UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT WILL BE AT-WILL, MEANING THAT EITHER PARTY CAN END THE EMPLOYMENT RELATIONSHIP AT ANY TIME AND FOR ANY OR NO REASON.
4.	I understand that any employment offer is contingent upon my providing, within three (3) working days of employment, valid proof od identity and eligibility to work in order to comply with the Immigration Reform and Control Act of 1986.
5.	I have read and reviewed the information provided in this application and the above statements. By signing this application for employment I certify that I understand all parts of it and have answered all questions completely and fully.
6.	I understand that by typing my name in the signature box below and submitting this application electronically, this becomes a legal and binding contract.
	Type Name in Signature Box:	Today's Date: 2010-09-07 16:31:13 CDT