"Employment Application Form"

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Employment Application
Programs, services, and employment are equally available to everyone. Please inform the Human Resources
Date of Review
(Month/Day/Year)
Department if you require reasonable accommodation for the application or interview.
/
/
Position Applied for:
APPLICANT DATA:
How were you referred to us:
Full name:
(LAST)
(FIRST)
(MIDDLE)
Address:
City:
State:
Zip:
Phone: (
)
Mobile/Pager/Other:
Email:
Date Available to Start:
Social Security #:
-
-
Salary Requirement:
q
q
If you are under 18 and we require a work permit, can you furnish one?
Yes
No
If no, please explain:
q
q
Have you ever worked for this company?
Yes
No
If yes, when?
q
q
Are you a citizen of the United States?
Yes
No
q
q
If not, are you legally allowed to work in the United States?
Yes
No
q
q
q
q
Type of employment desired:
Full-Time
Part-Time
Temporary
Seasonal
q
q
Have you ever pled “guilty,” “no contest,” or been convicted of a crime?
Yes
No
If yes, give dates and details:
Answering “yes” to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the
violation, rehabilitation, and position applied for will be considered.
Driver’s license number if applicable to position:
State:
SUMMARIZE YOUR SPECIAL SKILLS OR QUALIFICATIONS:
Page 1
HR104 • Rev. 04/04
Employment Application
Programs, services, and employment are equally available to everyone. Please inform the Human Resources
Date of Review
(Month/Day/Year)
Department if you require reasonable accommodation for the application or interview.
/
/
Position Applied for:
APPLICANT DATA:
How were you referred to us:
Full name:
(LAST)
(FIRST)
(MIDDLE)
Address:
City:
State:
Zip:
Phone: (
)
Mobile/Pager/Other:
Email:
Date Available to Start:
Social Security #:
-
-
Salary Requirement:
q
q
If you are under 18 and we require a work permit, can you furnish one?
Yes
No
If no, please explain:
q
q
Have you ever worked for this company?
Yes
No
If yes, when?
q
q
Are you a citizen of the United States?
Yes
No
q
q
If not, are you legally allowed to work in the United States?
Yes
No
q
q
q
q
Type of employment desired:
Full-Time
Part-Time
Temporary
Seasonal
q
q
Have you ever pled “guilty,” “no contest,” or been convicted of a crime?
Yes
No
If yes, give dates and details:
Answering “yes” to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the
violation, rehabilitation, and position applied for will be considered.
Driver’s license number if applicable to position:
State:
SUMMARIZE YOUR SPECIAL SKILLS OR QUALIFICATIONS:
Page 1
HR104 • Rev. 04/04
PREVIOUS EMPLOYMENT (begin with most recent position):
Dates of Employment:
From____/____/____
To____/____/____
Position(s) Held:
Firm:
Address:
Phone: (
)
Supervisor:
Title:
Responsibilities:
Starting Salary and Title:
Ending Salary and Title:
Reason for Leaving:
q
q
May we contact this employer for a reference?
Yes
No
Dates of Employment:
From____/____/____
To____/____/____
Position(s) Held: _____________________________________________
Firm:
Address:
Phone: (
)
Supervisor:
Title:
Responsibilities:
Starting Salary and Title:
Ending Salary and Title:
Reason for Leaving:
q
q
May we contact this employer for a reference?
Yes
No
Dates of Employment:
From____/____/____
To____/____/____
Position(s) Held:
Firm:
Address:
Phone: (
)
Supervisor:
Title:
Responsibilities:
Starting Salary and Title:
Ending Salary and Title:
Reason for Leaving:
q
q
May we contact this employer for a reference?
Yes
No
I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employ-
ment, educational, financial, and other related matters as may be necessary for an employment decision.
I hereby release employers, schools or individuals from all liability when responding to inquiries in connection with my application.
In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge.
Signature of Applicant: __________________________________________________________ Date: __________________________________________
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HR104 • Rev. 04/04
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