Employment Application

1. COMPANY OR EMPLOYER NAME:
2. POSITION APPLIED FOR:
3. APPLICANT TELEPHONE:
4. SOCIAL SECURITY NUMBER:
5. YOUR NAME (Last First Middle):
6. ADDRESS:
7. Are you able to perform the essential functions of the position with or without accommodations? Yes No
8. ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE U.S.A.? (If yes, verification will be required.) Yes No
9. I AM SEEKING A PERMANENT POSITION: Yes No

IF NECESSARY FOR THE JOB I AM ABLE TO:

1. Work (which shifts)? Select: Day Night
2. Work overtime? Yes No
3. Provide a valid Drivers License? Yes No
4. IF NECESSARY FOR THE JOB, ARE YOU OVER (Please mark one): 14 15 16 18 19 21
5. I WILL BE ABLE TO REPORT TO WORK DAYS AFTER BEING NOTIFIED THAT I AM HIRED.

EDUCATION:

High School

1. Yrs. Completed
2. Field of Study
3. Graduate or Degree

College/University

1. Yrs. Completed
2. Field of Study
3. Graduate or Degree

Business/Technical

1. Yrs. Completed
2. Field of Study
3. Graduate or Degree

Other (May include grammar school)

1. Yrs. Completed
2. Field of Study
3. Graduate or Degree

1. MILITARY SERVICE: Yes No
2. Duty/Specialized Training:

REFERENCES: List two personal references who are not relatives or former supervisors.

First Reference

1. Name
2. Address
3. Telephone
4. Occupation
5. Years known

Second Reference

1. Name
2. Address
3. Telephone
4. Occupation
5. Years known

EMPLOYMENT:

List last employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here, in the summary (following this section), or use an extra sheet of paper if necessary.

1st Employer

1. Employer Name and Address
2. Position Title/Duties Skills
3. Dates Employed
4. from
5. to
6. Supervisor's Name:
7. Supervisor's Telephone:
8. Reason for leaving:

2nd Employer

1. Employer Name and Address
2. Position Title/Duties Skills
3. Dates Employed
4. from
5. to
6. Supervisor's Name:
7. Supervisor's Telephone:
8. Reason for leaving:

3rd Employer

1. Employer Name and Address
2. Position Title/Duties Skills
3. Dates Employed
4. from
5. to
6. Supervisor's Name:
7. Supervisor's Telephone:
8. Reason for leaving:

4th Employer

1. Employer Name and Address
2. Position Title/Duties Skills
3. Dates Employed
4. from
5. to
6. Supervisor's Name:
7. Supervisor's Telephone:
8. Reason for leaving:

1. Summarize other employment related to this job:
2. Types of computers, other electronic or mechanical equipment that you are qualified to operate or repair:
3. Typing speed: symbols per minute.
4. Professional Licenses, Certifications or Registrations:
5. Additional skills including supervision skills, other languages, or information regarding the career/occupation you wish to bring to the employer's attention:

In case of accident or illness please contact:

1. Name
2. Address
3. Daytime phone
4. Relationship

Information to the applicant: As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references.

If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the US, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms.

I understand and agree to the information shown above

Equal Employment Opportunity While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment.