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.

Position(s) applied for

Date of Application

Last Name

First Name

Middle Name

Social Security #

Address

City

State

Zip

Telephone #

Mobile/Beeper/Other Phone #

E-mail

If you are under 18, and it is required, can you furnish a work permit?

Yes No

If no, please explain

Have you ever been employed here?

Yes No

If yes, give dates and positions:

Are you legally eligible for employment in this country?

Yes No

Date available for work

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?

Yes No

Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?

Yes No

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 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

State  None selected No US State Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

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 # 

Starting Job Title 

Final Job Title 

Address 

Immediate Supervisor and Title 

Summarize the nature of work performed and Job Responsibilities

May we contact for reference?
Yes No Later

Reason for leaving 

Hourly Rate/Salary
Start  per  Final  per 

From 

To 

Employer 

Telephone # 

Starting Job Title 

Final Job Title 

Address 

Immediate Supervisor and Title 

Summarize the nature of work performed and Job Responsibilities

May we contact for reference?
Yes No Later

Reason for leaving 

Hourly Rate/Salary
Start  per  Final  per 

From 

To 

Employer 

Telephone # 

Starting Job Title 

Final Job Title 

Address 

Immediate Supervisor and Title 

Summarize the nature of work performed and Job Responsibilities

May we contact for reference?
Yes No Later

Reason for leaving 

Hourly Rate/Salary
Start  per  Final  per 

From 

To 

Employer 

Telephone # 

Starting Job Title 

Final Job Title 

Address 

Immediate Supervisor and Title 

Summarize the nature of work performed and Job Responsibilities

May we contact for reference?
Yes No Later

Reason for leaving 

Hourly Rate/Salary
Start  per  Final  per 

Skills and Qualifications

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

Educational Background

(if job related)

High School

College

Major

Degree

Other

References

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with 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 (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 education 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 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 same right to terminate my employment at any time, with or without cause and without prior notices, except as may be require 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.

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