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application for employment

Full Name:
Full Address:
Phone Number:
Email:
Position applying for?
Date you can start:
Wage desired?
How did you hear of the position opening?
Were you referred by anyone? If so, name
Type of employment desired: FT PT Either
Have you submitted an application here before? Yes No
Have you been employed here before? Yes No    If yes, year
Are you 18 years or older? Yes No
Will you work overtime, if required? Yes No
Do you have a valid driver's license? Yes No
Are you able to lift 50 lbs? Yes No
May we contact your current employer
regarding information on this application? 		Yes No
Have you been convicted of a felony or
misdemeanor within the last 5 years? 		Yes No
(You will not be denied employment solely
because of a conviction record, unless the offense
is related to the job for which you applied.)

Please list references (include name, address and phone numbers)

Education

Name of School Address # of years Degree/Diploma

List any organizations or professional/business associates that you belong to:

Employment History

Dates Employed Name, Address, Telephone of Employer Beg Wage
End Wage		 Position
Job Responsibilities		 Reason for leaving
From:
To:
From:
To:
From:
To:
From:
To:

Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

List any additional information or comments you would like us to consider:

You may attach a resume in PDF or MS Word format.

Please read carefully:

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

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) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered.

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 to 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 such information in the employment process and all other person, corporations or organizations for furnishing such information about me.

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

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and 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 assurances to the contrary and that no implied oral or written agreements contract to the foregoing express language are valid unless they are in writing and signed by the employer's Administrator.

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

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

Date: