Application for Employment We are an equal opportunity employer and we do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify us. Date: Applicant Name (required): Position(s) applied for or type of work desired: Telephone # (required): E-mail (required): Social Security # (required): Type of employment desired: Full-timePart-timeTemporary Date you will be available to start work: Are you able to meet the attendance requirements? YesNo Do you have any objection to working overtime if necessary? YesNo Are you able to work any shift? YesNo Have you ever been previously employed by our organization? YesNo Can you submit proof of legal employment authorization and identity? YesNo If you are under 18, can you furnish a work permit if it is required? YesNo Have you been convicted of a crime in the last 7 years? YesNo If yes, please explain (a conviction will not automatically bar employment): Driver’s license number & expiration date (or State ID #) (required): How were you referred to us? Employment History (list last 3 employers) Please provide all employment information for your past four employers starting with the most recent. Employer: Position Held: Address: Telephone No: Immediate Supervisor and Title: Dates Employed: Salary: Job Summary: Reason for Leaving: Employer: Position Held: Address: Telephone No: Immediate Supervisor and Title: Dates Employed: Salary: Job Summary: Reason for Leaving: Employer: Position Held: Address: Telephone No: Immediate Supervisor and Title: Dates Employed: Salary: Job Summary: Reason for Leaving: Other Skills and Qualifications Summarize any job-related training, skills, licenses, certificates, and/or other qualifications: Education History List school name and location, years completed, course of study, and any degrees earned: High School: College: Technical Training: References Reference 1: Reference 2: Reference 3: In connection with my application for employment, I understand that an investigative consumer report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my: workers’ compensation injuries, driving record, criminal history, education, credentials, credit, and references. Medical and workers’ compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer-reporting agency. If so, I will be notified and given the name and address of the agency or the source that provided the information. I understand that a pre-employment drug screen may be required. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, we can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference, or insurance company contacted by ______________________ or their agent, to furnish the information described in paragraph 1 above. I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions. Applicant Signature: Date:
