Employment Application

Personal Information

Full Name *

Address *

Birthdate *

Phone *

Position(s) applying for *

If hired, on what date can you start working? *

Are you available to work overtime? *

YesNo

Salary/Hourly Rate Desired: *

If hired, would you have transportation to/from work? *

YesNo

Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age) *

YesNo

If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States? *

YesNo

If hired, are you willing to submit to and pass a controlled substance test? *

YesNo

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

YesNo

If no, describe the functions that cannot be performed:

(Note: company complies with the ADA and consider reasonable accommodation measures that may be necessary for eligible applications/employees to perform essential functions.)

Have you ever been convicted of a criminal offense (felony or misdemeanor)? *

YesNo

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

(Note: no applicant will be denied employment solely on the grounds of conviction of a criminal offense.)

Education, Training, & Experience

Name of high school you attended *

Years attended *

Did you graduate? *

YesNo

Name of college you attended (if applicable)

Years attended (if applicable)

Did you graduate?

YesNo

Name of Trade, Business, or Correspondence School (if applicable)

Years attended (if applicable)

Did you graduate?

YesNo

Work History (latest first)

Work History #1 (Latest)

Name of Employer *

Name of Supervisor *

Position *

Date Started *

Date Ended *

Reason for leaving *

May we contact? *

YesNo

Work History #2

Name of Employer

Name of Supervisor

Position

Date started

Date ended

Reason for leaving

May we contact?

YesNo

Work History #3

Name of Employer

Name of Supervisor

Position

Date started

Date ended

Reason for leaving

May we contact?

YesNo

References

Reference #1

Name *

Phone Number *

Occupation *

Years Acquainted *

Reference #2

Name *

Phone Number *

Occupation *

Years Acquainted *

Reference #3

Name *

Phone *

Occupation *

Years Acquainted *

Signature By my electronic signature below, I certify that all the statements herein are true and correct to the best of my knowledge and that any falsifications or willful omission on this application shall be sufficient cause for dismissal from or refusal of employment.

Full Name *

Date *