Application for Employment

Personal Information

Referral Source*

Please check the appropriate category and list the source in the text field.

Referral Source Checkboxes
Referral list source description

Additional Details

Best time to call phone number*
May we contact you at work?*

If you are under 18 and it is required, can you furnish a work permit?

Have you submitted an application here before?*
Have you ever been employed here before?*
Is this application a request for reemployment following an extended military leave of absence from this company?

If yes, additional information may be requested.

Are you legally eligible for employment in this country?*
What is your desired salary range or hourly rate to pay?*

Type of employment desired*

Will you relocate if job required it?*
Will you travel if job requires it?*
If they have been explained to you, are you able to meet the attendance requirements of the position?*
Will you work overtime if required?*

Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)?*
This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage, to the extent permitted by law.

Have you ever been bonded?*
Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as the date of offense, seriousness and nature of the violation, rehabilitation is necessary. These issue may be addressed at a later stage to the extent permitted by law.
Have you ever pleaded "guilty" or "no contest" to or been convicted of a crime?*

Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?*

Employment History

Starting with your most recent employer, provide the following information. Minimum one required.

Employer One*
Employer one May we contact employer?*

Employer Two
Employer two May we contact employer?

Employer Three
Employer three May we contact employer?

Employer Four
Employer four May we contact employer?

Employment History continued
If not addressed on previous page, have you ever been fired or asked to resign from a job?*

Skills and Qualifications

Computer Skills*

Check appropriate boxes. Include software titles and years of experience.

Computer Skills

Educational Background

Starting with your most recent school attended, provide the following information. Minimum one required

School One*
School one Level completed*

School Two
School two Level completed

School Three
School three Level completed

School Four
School four Level completed


List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors.
If not applicable, list three school or personal references who are not related to you.

Reference One

Reference Two

Reference Three

Social Security Number

We will use this information only for employment purposes and make reasonable efforts to safeguard your privacy.

Related Information

To what job-related organizations (professional, trade, etc.) do you belong?

Exclude memberships that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status.

Organization One
Organization Two
Organization Three

In your current or a previous job, have you ever written instructions or directions to be followed by employees or customers?*

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurance to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status under application federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, genetic information, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Background Check
Disclosure & Authorization

Disclosure to Applicant/Employee That a Consumer Report May Be Obtained by Employer

Please note that in connection with your application for employment and/or ongoing employment with our Company, we may obtain a "consumer report," as defined in the Fair Credit Reporting Act (FCRA), from a consumer reporting agency. Consumer reports include, but are not limited to, credit reports, criminal background checks and motor vehicle reports.

Authorization for Employer to Obtain Consumer Report

By signing below, I hereby acknowledge that I have read the above disclosure and voluntarily authorize the Company, including its agents and representatives, to obtain a consumer report on me for use in connection with my application for employment or ongoing employment with the Company. If hired or currently employed, I understand that this authorization will remain on file and will serve as an ongoing authorization, to the extent permitted by law, for a consumer report to be lawfully obtained at any time in connection with my employment.

I further understand that the Company will provide me a copy of the consumer report if the information in the report is used, in any way, to make decisions regarding my fitness for employment or ongoing employment with the Company. I understand that the report will be made available to me before any employment decisions are made, along with a summary of my rights under the Fair Credit Reporting Act.

The following information is necessary to confirm your identity for completing an accurate background check.
It is confidential and will not be taken into consideration in any employment decisions.

Please print

Please list previous addresses for the past seven years (in chronological order)
1st Previous Address *

2nd Previous Address

3rd Previous Address

Employer: Keep the Background Check Disclosure & Authorization form separate from other employee personal records.
Give applicant/employee a copy of this form and retain the original for you records.

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