Application for EmploymentNameApplicant ID #Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeHome PhoneCell/Other PhoneEmail AddressPosition(s) applied forApplication DateReferral Source (e.g., Walk-in, Job Posting, Company's Website, etc.)ContactIf necessary, the best time to call you isHoursMinutesAMPMWhich Number?HomeCell/OtherMay we contact you at work?YesNoIf yes, work numberBest time to callHoursMinutesAMPMIf you are under 18 and it is required, can you furnish a work permit?N/AYesNoIf no, please explainHave you submitted an application here before?YesNoIf yes, please give date(s) and position(s):Have you ever been employed here before?YesNoFromToIs this application a request for reemployment following an extended military leave of absence from this company?YesNoIf yes, additional information may be requested.Are you lawfully authorized to work in the United States?YesNoDate available for workWhat is your desired salary range or hourly rate of pay?PerHourMonthYearType of employment desired:Full -TimePart -TimeEducational Co-OpSeasonalTemporaryWill you relocate if job requires it?YesNoWill you travel if job requires it?YesNoIf they have been explained to you, are you able to meet the attendance requirements of the position?N/AYesNoWill you work overtime if required?YesNoIf no, please explain:Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accomodation)?YesNoNeed more information about the job's "essential functions" to respondThis question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accomodation or whether accomodation is necessary. These issues may be addressed at a later stage to the extend permitted by law.Driver's license number required if driving may be required in the job for which you are applying:State/ProvinceHave you ever been bonded?YesNoHave 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?YesNoIf yes, please explain:Employment HistoryStarting with your most recent employer, provide the following information. You may include any verified work performed under a volunteer basis.Field GroupEmployerPhoneStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeStarting job title/final job titleDates EmployedImmediate supervisor and title (for most recent position held)May we contact for reference?YesNoEmail AddressWhy did you leave?Summarize the type of work performed and job responsibilities.What did you like most about the position?What were the things you liked least about the position?Employment History (continued)Explain any gaps in your employment, other than those due to personal illness, injury, or disability.If not addresses on previous page, have you ever been fired or asked to resign from a job?YesNoIf yes, please explain:Skills and QualificationsSummarize any special training, skills, languages, licenses, and/or cerifications that may assist you in performing the position for which you are applying:Word ProcessingSoftware TitleSelectBasicIntermediateAdvancedSpreadsheetSoftware TitleSelectBasicIntermediateAdvancedPresentationSoftware TitleSelectBasicIntermediateAdvancedE-mailSoftware TitleSelectBasicIntermediateAdvancedInternetSoftware TitleSelectBasicIntermediateAdvancedOtherSoftware TitleSelectBasicIntermediateAdvancedOtherSoftware TitleSelectBasicIntermediateAdvancedOtherSoftware TitleSelectBasicIntermediateAdvancedEducational BackgroundStarting with your most recent school attended, provide the following information:SchoolCityState/Province# of years completedCompletedDiplomaGEDDegreeCertificationOtherGPA/Class RankMajor/MinorReferencesList 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.NameTitleRelationship to youPhoneEmail AddressNumber of years knownRelated InformationWhen answering these questions, please exclude any information that would reveal sex (including pregnancy), race, color, religion, national origin, citizenship, age, disability, genetic information, or other similaly protected status.To what job-related organizations (professional, trade, etc.) do you belong?List special accomplishments, plublications, awards, etc.Is there any other job-related information you want us to know about you?Applicant StatementI 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 waiw 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 emplorment and no question on this application is used for the purpose oflimiting 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 60 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 ncccssarr for me to reappl)' 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 1he 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 docs 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 contrary to the foregoing express language arc valid unless they arc in wriling 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 Stales and I hat federal immigration laws require me to complete an 1-9 Form in this regard. I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. M)' personal information may be shared wi1h the employer's affiliate(s) and third parties engaged by the emplorer to perform services for the cmplo)'er. Any personal information shared with an affiliate or third party is to be used solely to perform the services requested by the cmplorer. This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose oflimiting or excluding an applicant from consideration for employment on the basis of his or her sex (including pregnancy), race, color, religion, national origin, citizenship, age, disability, genetic information, or any other protected status under applicable federal, state, or local law. Mandatory Emplorer Disclosures Noticctolfaryland applicants: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT.OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING SIOO. Notice lo Massachusetts applicants: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. Notice lo Rhode Island applicants: This company complies with Rhndc Island law prohibiting smoking in enclosed areas within places of employment. Notice to North Dakota applicants: This company complies with North Dakota law prohibiting smoking within 20 feet of entrance and inside places of employment. Notice to Indiana applicants: This company complies with Indiana law prohibiting smoking in enclosed areas within places of employment. 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.DO NOT SIGN UNTIL YOU HAVE READ THE A.BOVE APPLICANT STATEMENT.I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.Signature of ApplicantStart signing your signature hereYour browser does not support e-Signature field.Print Name *DateSubmit ApplicationSave as DraftPlease do not fill in this field. Please do not fill in this field.
