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Application for Employment

Our policy is to provide equal employment opportunity to all qualified persons without
regard to race, creed, color, religious belief, sex, age, national origin, ancestry, physical or
mental disability, or veteran status.

Ngày ______________
Last name ________________________ First name ________________ Middle
name________
Street Address
_________________________________________________________________
City _____________________ State _______ ZIP _______
Điện thoại ___________________________ Social Security #
___________________________

Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted
basis? (You may be required to provide documentation.)  Yes  No
Are you looking for full-time employment?  Yes  No
If no, what hours are you available? ______________
Are you willing to work swing shift?  Yes  No
Are you willing to work graveyard?  Yes  No
Have you ever been convicted of a felony? (This will not necessarily affect your
application.)
 Yes  No
If yes, please describe conditions.
_________________________________________________
________________________________________________________________________
______
________________________________________________________________________
______

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________________________________________________________________________
______
________________________________________________________________________
______

Employment Desired
Position applied for __________________________________________
How did you hear of this opening? __________________________________________
Have you ever applied for employment here?  Yes  No
When? ___________________________________ Where?
___________________________________
Have you ever been employed by this company?  Yes  No
When? ___________________________________ Where?
___________________________________
Are you presently employed?  Yes  No
May we contact your present employer?  Yes  No
Are you available for full-time work?  Yes  No
Are you available for part-time work?  Yes  No
Will you relocate?  Yes  No
Are you willing to travel?  Yes  No If yes, what percent?
__________________________
Date you can
start_______________________________________________________________
Desired
position________________________________________________________________
Desired starting
salary___________________________________________________________
Please list applicable
skills________________________________________________________
________________________________________________________________________
______

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________________________________________________________________________
______

Education
School Name and Location Year Major
Degree
High School ________________________________________ ______ _________
______
College ___________________________________________ ______ _________
______
College ___________________________________________ ______ _________
______
Post-College _______________________________________ ______ _________
______
Other Training ______________________________________ ______ _________
______
In addition to your work history, are there are other skills, qualifications, or experience
that we should consider?
________________________________________________________________________
______
________________________________________________________________________
______
________________________________________________________________________
______
________________________________________________________________________
______
________________________________________________________________________
______
Please list any scholastic honors received and offices held in school.
________________________________________________________________________
______
________________________________________________________________________
______
Are you planning to continue your studies?  Yes  No

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If yes, where and what courses of study?

________________________________________________________________________
______
Employment History (Start with most recent employer)
Company Name
________________________________________________________________
Address ________________________________________Telephone
______________________
Date Started ____________ Starting Wage ____________ Starting Position
_______________
Date Ended _____________ Ending Wage ____________ Ending Position
________________
Name of Supervisor ____________________________________
May we contact?  Yes  No
Responsibilities
________________________________________________________________
________________________________________________________________________
______
Reason for leaving
______________________________________________________________

Company Name
________________________________________________________________
Address _______________________________________ Telephone
______________________
Date Started ___________ Starting Wage ____________ Starting Position
________________
Date Ended _____________ Ending Wage ____________ Ending Position
________________
Name of Supervisor ____________________________________
May we contact?  Yes  No
Responsibilities
________________________________________________________________

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________________________________________________________________________
______
Reason for leaving
______________________________________________________________

Company Name
________________________________________________________________
Address _______________________________________ Telephone
______________________
Date Started ___________ Starting Wage ____________ Starting Position
________________
Date Ended ___________ Ending Wage ____________ Ending Position
__________________
Name of Supervisor ____________________________________
May we contact?  Yes  No
Responsibilities
________________________________________________________________
________________________________________________________________________
______
Reason for leaving
_____________________________________________________________

Company Name
_______________________________________________________________
Address _______________________________________ Telephone
______________________
Date Started ___________ Starting Wage ____________ Starting Position
________________
Date Ended ____________ Ending Wage ____________ Ending Position
_________________
Name of Supervisor ____________________________________
May we contact?  Yes  No

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Responsibilities
________________________________________________________________
________________________________________________________________________
______
Reason for leaving
______________________________________________________________

Company Name
________________________________________________________________
Address _______________________________________ Telephone
______________________
Date Started ___________ Starting Wage ____________ Starting Position
________________
Date Ended ____________ Ending Wage ____________ Ending Position
_________________
Name of Supervisor ____________________________________
May we contact?  Yes  No
Responsibilities
________________________________________________________________
________________________________________________________________________
______
Reason for leaving
______________________________________________________________

Company Name
________________________________________________________________
Address _______________________________________ Telephone
______________________
Date Started ___________ Starting Wage ____________ Starting Position
________________
Date Ended ____________ Ending Wage ____________ Ending Position
_________________
Name of Supervisor ____________________________________

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May we contact?  Yes  No

Responsibilities
________________________________________________________________
________________________________________________________________________
______
Reason for leaving
______________________________________________________________

References
List three personal references, not related to you, who have known you for more than one
year.
Name ____________________________ Phone ____________________Years
Known_______
Address
______________________________________________________________________
Name ____________________________ Phone ____________________Years
Known_______
Address
______________________________________________________________________
Name ____________________________ Phone ____________________Years
Known_______
Address
______________________________________________________________________

Emergency Contact
In case of emergency, please notify:
Name ______________________________________________ Phone
____________________
Address
______________________________________________________________________
Name ________________________ Phone ____________________
Address
______________________________________________________________________

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Please Read Before Signing:

I certify that all information provided by me on this application is true and complete to
the best of my knowledge and that I have withheld nothing that, if disclosed, would alter
the integrity of this application.
I authorize my previous employers, schools, or persons listed as references to give any
information regarding employment or educational record. I agree that this company and
my previous employers will not be held liable in any respect if a job offer is not extended,
or is withdrawn, or employment is terminated because of false statements, omissions, or
answers made by myself on this application. In the event of any employment with this
company, I will comply with all rules and regulations as set by the company in any
communication distributed to the employees.
In compliance with the Immigration Reform and Control Act of 1986, I understand that I
am required to provide approved documentation to the company that verifies my right to
work in the United States on the first day of employment. I have received from the
company a list of the approved documents that are required.
I understand that employment at this company is “at will,” which means that either I or
this company can terminate the employment relationship at any time, with or without
prior notice, and for any reason not prohibited by statute. All employment is continued on
that basis. I hereby acknowledge that I have read and understand the above statements.
Signature _______________________________________________
Date_________________

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