Full Address* (Include: Street Number, Town, State, Zip Code)
If hired, do you have a reliable means of transportation to get to work?*YesNo
Describe your transportation*
Are you at least 18 years old?*YesNo
If you are under 18, can you furnish a work permit?YesNo
Are you legally eligible for employment in the U.S.?*YesNo
(Proof of U.S. citizenship or immigration status is required if hired.)
Have you been convicted of a crime?*YesNo
If yes, state the nature of the offense and disposition of the case. Include dates and places. (NOTE: The existence of a criminal record does not constitute an automatic bar to employment).
Are you a veteran?*YesNo
If yes, give dates of service:
List any special skills or training:
What type of Employment are you seeking?*
Full TimePart TimeTemporary
What hours and shift(s) would you prefer to work?*
List times you are not available to work:
Are you willing to work overtime?*YesNo
Are you currently employed?*YesNo
If hired, when would you able to start?*
Have you ever worked for this organization before?*YesNo
List any friends or relatives employed by this company:
Have you ever been discharged or asked to resign from any position?*YesNo
If yes, please describe:
If applicable, please refer to the attached job description for the position for which are you applying. Are you able to perform all these tasks with or without reasonable accommodation?*YesNo
Please describe which tasks, if any, you will need accommodation to perform, and explain what type of accommodation you will need:
What is your highest level of education?*
Some HighschoolHighschool GraduateSome CollegeCollege GraduateGraduate School
Name of Most Recent School:
Full Address of Most Recent School:
If in high school, are you enrolled in a recognized co-op program?YesNo
If yes, identify program and school:
If in college, what is your degree or major?
If in college, what is your minor?
Begin with most recent. May we contact these employers?*YesNo
Address: (Include: Street Number, Town, State, Zip Code)
Dates of Employment:
Supervisor Name & Title:
Describe duties briefly:
Reason for leaving:
I certify that I have personally completed this application. I declare that the information provided in this employment application is true and complete and I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification for my dismissal from employment if discovered at a later date. I agree to immediately notify this company if I should be convicted of a crime while my job application is pending or during my employment, if hired.
I authorize this company to make an investigation of all information contained in this employment application and I release from liability all companies and corporations supplying such information. I understand any false answers, statements, or implications made by me on this application or other required documents shall be considered sufficient cause for denial of employment or discharge.
I specifically authorize and direct my current and former employers to supply employment-related information to this company and do hereby release my current and former employers from liability for providing information to this company.
Upon termination of my employment for whatever reason, I release this company from all liability for supplying any information concerning your employment to any potential employer.
I authorize this company, if applicable, to request a copy of my credit report, motor vehicle driving record, and any other investigative report deemed necessary through various third party sources. As required by law, upon request within a reasonable period of time, I will be notified as to the nature and scope of investigations.
I hereby agree to submit to any drug test required of me, whether prior to my employment or if employed by this company at any time thereafter. If requested, I will take a post-job offer physical examination and my employment, in the event I receive medical treatment for any condition including a physical, psychological, emotional, or psychiatric condition that is job-related, I hereby authorize the limited release and exchange of such medical information relating to my condition between the treatment provider and a company-designated physician.
At-Will Employment Agreement
I understand and agree that nothing contained in this application, or conveyed during any interview is intended to create an employment contract between the company and me. In addition, I understand and agree that if you employ me, in consideration of my employment, my employment and compensation will be at-will, for no definite period of time, and may be terminated at any time, for any reason, or for no reason at all. I understand that only the company’s president is authorized to change the employment-at-all status and such a change can only be done in writing. I have read, understand, and agree to the above.