Today's Date
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MM
DD
YYYY
Name
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First Name
Last Name
Are you 18 years of age or older?
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Social Security Number
Phone
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(###)
###
####
Email
Current Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Length of Time at This Address:
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Previous Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Length of Time at Previous Address:
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Rate of Pay Expected:
Rate of Pay Expected:
Do You Want To Work:
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If applying for part time, what days and hours?
Have you ever applied to work with us before?
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If yes, when?
List anyone you know that works for us:
Do you have any skills, qualifications or experiences which you feel would especially fit you for work with us?
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U.S. Armed Forces Service?
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If yes, from:
Branch of Service:
Rank or rating at time of enlistment:
Rating at time of discharge:
Were you dishonorably discharged?
If yes, explain:
Are you able to do the essential functions of the job(s) for which you are applying?
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If no, please identity the applicable functions:
How much time have you lost from work or school during the past two calendar years FOR REASONS OTHER THAN VACATION AND HOLIDAYS?
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Prior Year
Do you have any activities, commitments, or responsibilities (for example: car pooling, school, other employment) which might in any way restrict the hours (including overtime) or days you can work?
Have you ever been convicted of a crime (including a guilty or no contest plea?)
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If yes, explain when, where, and the nature of the offense:
Are there any felony charges pending against you now?
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If yes, describe:
Are you authorized to work in the United States?
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If hired, when can you start?
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Years Attended:
Name Of School:
Location:
Course:
Did you graduate?
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Years Attended:
Name of School:
Location:
Course:
Did you graduate?
Years Attended:
Name of School:
Location:
Course:
Name of Employer:
Address of Employer:
Dates of Employment:
Type of Work:
Starting Pay:
Final Pay:
Reasons for Leaving:
Name of Employer:
Address of Employer:
Dates of Employment:
Type of Work:
Starting Pay:
Final Pay:
Reasons for Leaving:
Name of Employer:
Starting Pay:
Final Pay:
Reasons for Leaving:
Relevant Experience:
Reference #1
First Name
Last Name
Phone:
(###)
###
####
Address:
Occupation:
Reference #2
First Name
Last Name
Phone:
(###)
###
####
Address:
Occupation:
Reference #3
First Name
Last Name
Phone:
(###)
###
####
Address:
Occupation:
APPLICANT'S CERTIFICATION AND AGREEMENT
PLEASE READ CAREFULLY
1. Certification of Truthfulness.
I certify that all statements on this Application for Employment are complete and truthful and agree that such statements may be investigated and if found to be false will be sufficient reason for not being employed, or if employed may result in my dismissal.
2. Authorization for Employment/ Educational Information.
I authorize the references listed in this Application for Employment, and any prior employer, educational institution, or any other persons or organizations to give this Company any and all information concerning my previous employment/ educational accomplishments, disciplinary information or any other pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I hereby waive written notice that employment information is being provided by any person or organization.
3. Employment at Will.
If I am hired, in consideration of my employment, I agree to abide by the rules and policies of this Company, including any changes made from time to time, and agree that my employment and compensation can be terminated with or without cause, and with or without notice, at any time, at the option of either the Company or myself. I understand that no manager or other representative of the Company, other than the President, has any authority to enter into any agreement for employment for any specific or indefinite period of time, or to make any agreement contrary to the foregoing. Any such agreement made by the President must be made in writing to be effective.
4. Authorization to Work.
If I am selected for hire, I will be offered employment provided I verify that I am authorized to work as required by the Immigration Reform and Control Act of 1986.
5. Limitation on Claims.
I agree that any lawsuit or claim against the Company arising out of my employment or termination of employment (including, but not limited to, claims arising under state, federal or local civil rights laws) must be brought within the following time limits or be forever barred: (a) for lawsuits requiring a Notice of Rights to Sue from the EEOC, within 90 days after the EEOC issues that Notice; or (b) for all other lawsuits, within (i) 180 days of the event(s) giving rise to the claim, or (ii) the time limit specified by statute, whichever is shorter. I waive any statute of limitations that exceeds this time limit.
6. Need for Accommodation.
If I have a mental or physical disability and require an accommodation to perform the job, I must notify the Company of that need in writing within 182 days after I knew or reasonably should have known that an accommodation was needed. Failure to do so will bar me from alleging that the Company has not accommodated me as required by law.
7. Criminal Records Check.
I authorize the Company to secure my criminal conviction history. I agree to execute the appropriate authorization if necessary to obtain such information.
8. Driving Record Check.
I agree to execute an authorization for this employer to inquire into, and obtain documents related to, any driving record from every state in which I have held a motor vehicle operator's license or permit.
9. Release of Medical Information.
I authorize every medical doctor, physician or other health care provider to provide any and all information, including but not limited to, all medical reports, laboratory report, X-rays or clinical abstracts relating to my previous health history or employment in connection with any examination, consultation, test or evaluation. I hereby release every medical doctor, health care personnel and every other person, firm, officer,
corporation, association, organization or institution which shall comply with the authorization or request made in this respect from any and all liability. I understand that this release will not be sent to my physician or other health care provider until a conditional job offer has been made.
10. Physical Exam and Drug and Alcohol Testing.
I agree to take a physical exam following a conditional job offer. I also authorize the Company or its designated agent(s) to withdraw specimen(s) of my blood, urine, hair and/or other substances for chemical analysis. One purpose of the analysis is to determine or exclude the presence of alcohol, drugs or other substances. I understand that decisions concerning my employment may be made as a result of these tests.
11. Consideration for Employment.
I understand that my application will be considered pursuant to the Company's normal procedures for a period of thirty-(30) days. If I am still interested in employment thereafter, I must reapply.
Date
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MM
DD
YYYY
Digital Signature
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I agree that by entering my name below it is permissable as my signature
First Name
Last Name
