Application for Employment

  *required fields
Personal Information:  
Name*:  
Address*:  
Address2:
City*:  
State*:   (ex. PA)
Zip Code*:  
Home Phone*:   (ex. 6107778888, no dashes)
Alternate Phone:  
Referred by:  
   
Employment Desired:  
Position*:  
Date you can start*:  
Salary desired*:   per hr.
Are you employed now?*:  
If so, may we inquire of your present employer?*:  
Are you legally authorized to work in the United States?*:  
Ever applied to this company before?*:  
   
Education History:  
High School Name:  
Year graduated:  
College Name:
Year graduated:  
Trade or Business School Name:
Year graduated:  
   
General Information:  
Subject of special study/research work:  
Special training:  
Special skills:  
U.S. Military Service (branch):  
Rank:  
   
Employment History: (List last three employers, starting with most recent)
Name of Employer:  
Address:  
Position:  
Salary:  
Dates of employment: to
Reason for leaving:  
   
Name of Employer:  
Address:  
Position:  
Salary:  
Dates of employment: to
Reason for leaving:  
   
Name of Employer:  
Address:  
Position:  
Salary:  
Dates of employment: to
Reason for leaving:  
   
References: (list three)
Name*:  
Address*:  
Phone*:   (ex. 6107778888, no dashes)
Business:  
Years known*:  
   
Name*:  
Address*:  
Phone*:   (ex. 6107778888, no dashes)
Business:  
Years known*:  
   
Name*:  
Address*:  
Phone*:   (ex. 6107778888, no dashes)
Business:  
Years known*:  
   
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has no authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.
   
Signature:  
Date: