Employment Application Applicant Information First Name Last Name Date Address City, State, Zip Phone Email Date Available Position Applied for Are you a citizen of the United States? YesNo If no, are you authorized to work in the U.S.? YesNo Have you ever worked for this company? YesNo If yes, when? Have you ever been convicted of a felony? YesNo If yes, explain: Education High School Address From: To: Did you graduate? YesNo Diploma College Address From: To: Did you graduate? YesNo Degree Other Address From: To: Did you graduate? YesNo Degree References Reference #1 Full Name Relationship Company Phone Address Reference #2 Full Name Relationship Company Phone Address Reference #3 Full Name Relationship Company Phone Address Previous Employment Company Phone Address Supervisor Job Title Starting Salary Ending Salary Responsibilities From: To: Reason for Leaving May we contact your previous supervisor for a reference? YesNo Company Phone Address Supervisor Job Title Starting Salary Ending Salary Responsibilities From: To: Reason for Leaving May we contact your previous supervisor for a reference? YesNo Company Phone Address Supervisor Job Title Starting Salary Ending Salary Responsibilities From: To: Reason for Leaving May we contact your previous supervisor for a reference? YesNo Military Service Branch From: To: Rank at Discharge Type of Discharge If other than honorable, explain: Special training, skills, licenses, and/or certificates Special training, skills, licenses, and/or certificates Upload Resume Disclaimer and Signature I certify that all 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 cancel further consideration or immediately discharge me from employer’s service, whenever it is discovered. I expressly authorize, without reservation, the employer, it’s 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 waive any and all rights and claims I may have regarding the employer, it’s agents, employees or representatives for seeking, gathering and using such information in the employment process and all other persons, 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 contrary to the foregoing express language are valued unless they are in writing and signed by employer’s owners. 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. By signing this application, I certify that I have read, fully understand and accept all terms of this disclaimer. Signature (type your name) Date Δ
