EMPLOYMENT APPLICATION

LAST NAME FIRST MIDDLE CELL:

EMAIL:

STREET ADDRESS APT. NO. CITY STATE ZIP CODE

PLEASE LIST PREVIOUS ADDRESS IF YOU HAVE BEEN AT THE ABOVE ADDRESS FOR LESS THAN 7 YEARS:
STREET ADDRESS APT. NO. CITY STATE ZIP CODE

LAST 4 DIGITS OF SOC. SEC. NO.. ARE YOU OVER THE AGE OF 18?  YES  NO

LIST ALL OTHER NAMES THAT YOU HAVE USED INCLUDING BUT NOT LIMITED TO ALL OTHER NAMES UNDER WHICH YOU HAVE WORKED OR ATTENDED SCHOOL:

HAVE YOU APPLIED FOR A POSITION WITH

ARE YOU A U.S. CITIZEN OR AN ALIEN LAWFULLY AUTHORIZED BY THE IMMIGRATION AND NATURALIZATION ANY OFFICE OF THIS COMPANY BEFORE?
SERVICES TO WORK IN THE UNITED STATES?
 YES
 YES  NO IF YES, WHEN? MONTH____ YEAR____

POSITION:____________________
HAVE YOU EVER HAD A PROFESSIONAL LICENSE REVOKED?
LOCATION:____________________
 YES  NO
 NO

POSITION AND LOCATION SALARY/HOURLY RATE DESIRED

LIST PC SKILLS/SOFTWARE: MANNER OF INTRODUCTION (I.E., JOB BOARD, AGENCY, ETC.)

AVAILABILITY:
WHAT TIME ARE YOU AVAILABLE EACH DAY OF THE WEEK? PLEASE ENTER YOUR AVAILABLE START AND END TIMES IN THE BOXES
BELOW.

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

ARE YOU APPLYING FOR A SEASONAL OR TEMPORARY POSITION?

 YES  NO

1
 EDUCATION:

# YEARS NAME OF SCHOOL ADDRESS DID YOU GRADUATE? DEGREE

COMPLETED YES
HIGH
SCHOOL/GED
COLLEGE
GRADUATE
SCHOOL
OTHER (INCLUDES
MILITARY TRAINING)

EMPLOYMENT APPLICATION

Employment History
DATE POSITION SALARY REASON FOR
NAME, ADDRESS AND PHONE NUMBER OF LEAVING
FROM TO
MO/YR MO/YR CURRENT AND PREVIOUS EMPLOYERS (INCLUDING MILITARY EXPERIENCE)
NAME PHONE

ADDRESS CITY STATE ZIP

DIRECT SUPERVISOR’S NAME CURRENT PHONE NUMBER

NAME PHONE

ADDRESS CITY STATE ZIP

DIRECT SUPERVISOR’S NAME CURRENT PHONE NUMBER

NAME PHONE

ADDRESS CITY STATE ZIP

DIRECT SUPERVISOR’S NAME CURRENT PHONE NUMBER

________________ _________________________________________________________
DATE APPLICANT SIGNATURE

_________________________________________________________
INTERVIEWER
 Applicant Authorization for Criminal Background Check
and Release of Records

During the employment application process and at any time while employed by Opitz &
Associates, I hereby authorize Opitz & Associates to procure a National Criminal
Background Check.

This report may be compiled with information from multiple criminal record sources
including:

 Department of Corrections prison, parole and release files

 Administrative Office of Court Records
 State Criminal Records repositories
 Individual county court records
 Sex Offender Registries
 ChoicePoint proprietary criminal record data
 Any other source required to verify information that I have voluntarily supplied

I understand that if for any reason the information provided to Opitz & Associates causes my
employment application to be rejected, my offer of employment to be rescinded, or my
employment with Opitz & Associates to be terminated, I may obtain a free copy of the report
within 60 days and I have the right to dispute the accuracy of the information with Opitz &
Associates.

Applicant Signature Date

Print Name

Social Security Number:

Date of Birth:
Address:

City: State: Zip Code: