Application for Employment

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Positions(s) applied for:
First Name:
Middle Name:
Last Name:
Social Security Number:
Address:
City, State, Zip:
Phone #:
Mobile, Pager, Other Phone #:
Email Address:
If you are under 18, and it is required, can you furnish a work permit?
If no, please explain:
Have you ever been employed here before?
(Check for Yes)
If yes, give dates and positions:
Are you legally eligible for employment in this country?
(Check for Yes)
Date available for wok:
What is your desired salary range?
Type of employment desired:
Full Time
Part Time
Temporary
Seasonal
Educational Co-op
Are you able to meet the attendance requirements of the position?
(Check for Yes)
Have you ever pled "guilty" or "no contest" or been convicted of a crime?
(Check for Yes)
If yes, please provide date(s) and details:
Answering 'yes' to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and the nature of the violation, rehabilitation and position applied for will be taken into account.
Driver's license number if driving is an essential job function:
Driver's license state:

Employment History

Provide the following information of your past four (4) employers, assignments or volunteer activities, starting with the most recent.

From:
To:
Employer:
Telephone:
Address:
Starting Job Title/Final Job Title:
Summarize the nature of work performed and responsibilities:
Immediate supervisor and title:
May we contact for reference?:
(Check for Yes)
Reason for leaving:
Start hourly rate/salary:
Final hourly rate/salary:

From:
To:
Employer:
Telephone:
Address:
Starting Job Title/Final Job Title:
Summarize the nature of work performed and responsibilities:
Immediate supervisor and title:
May we contact for reference?:
(Check for Yes)
Reason for leaving:
Start hourly rate/salary:
Final hourly rate/salary:

From:
To:
Employer:
Telephone:
Address:
Starting Job Title/Final Job Title:
Summarize the nature of work performed and responsibilities:
Immediate supervisor and title:
May we contact for reference?:
(Check for Yes)
Reason for leaving:
Start hourly rate/salary:
Final hourly rate/salary:

From:
To:
Employer:
Telephone:
Address:
Starting Job Title/Final Job Title:
Summarize the nature of work performed and responsibilities:
Immediate supervisor and title:
May we contact for reference?:
(Check for Yes)
Reason for leaving:
Start hourly rate/salary:
Final hourly rate/salary:

Skills and Qualifications

Summarize any training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

Educational Background

(if job related)
  Name Location Years Completed Graduate/Degree Course of Study or Major
High School
College
Other School

References

Name Telephone Number of Years Known

Application Statement

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 be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered.

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 waive any and all rights and claims I may have regarding the employer, its 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.

I understand that this application remains current for only 30 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 necessary to reapply 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 without prior notice, and the employer reserves the 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 valid unless they are in writing 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 authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I certify that I have read, fully understand, and accept all terms of the foregoing Applicant Statement.

An equal opportunity employer