Identifying Information:
  = Required Fields
First Name: Middle Initial:
Last Name:
Social Security Number:
Present Mailing Address:
City:
State:
Zip Code:
Home Phone: ###-###-####
Work or Message Phone: ###-###-####
E-mail address: (if any)
Are you at least
18 years of age?
Position Desired:
Do you wish to work:
Availability:
(Please check all that apply)
Date available for work:
Other skills:
 
 Employment History:
In the following spaces please give a complete record of your employment. Begin with your most recent employment and work back. If you wish to include more than three past employers, please use the space below titled "Additional Employers".
Employer:
Address:
Telephone: ###-###-####
Supervisor:
Starting Position: Last Position:
Starting Salary: Final Salary:
Employed From: (MM/YY) Employed To: (MM/YY)
Duties:
Reason for Leaving:
Employer:
Address:
Telephone: ###-###-####
Supervisor:
Starting Position: Last Position:
Starting Salary: Final Salary:
Employed From: (MM/YY) Employed To: (MM/YY)
Duties:
Reason for Leaving:
Employer:
Address:
Telephone: ###-###-####
Supervisor:
Starting Position: Last Position:
Starting Salary: Final Salary:
Employed From: (MM/YY) Employed To: (MM/YY)
Duties:
Reason for Leaving:
Additional Employers:
 
 Questionnaire:
  Have you previously applied for employment with us?           
     If yes, when and where?
     
In order to permit a check of your work and education records, please indicate any other names you have used in the past:
     
Have you ever been convicted of a criminal offense?     
     (A conviction will not necessarily disqualify an applicant)
     If yes, please explain:
     
 
Use this space to give us further information which you think is important for us to know in relationship to this job.
     
 
 Agreement:
Please read the following statements carefully and indicate you have done so by entering your name and today's date in the fields below:
 
 

I hereby affirm that the information provided on this application form (and accompanying resume, if any) is true and complete to the best of my knowledge and agree to advise this Company, in writing, of any change or addition to any information contained in this application. I agree that false information or the omission of information from this Application (including leaving blanks on this Application or my failure to correct or add to the information changes during the course of my employment) ("Inaccurate Information") may disqualify me from consideration for employment or continued employment and may well result in my immediate dismissal if discovered at a later date. I further agree to hold harmless and indemnify the property and this Company from any and all liability that may be caused by the Company relying on Inaccurate Information.

I authorize the investigation of my past employment and other qualifications of employment as deemed appropriate and agree to cooperate in such investigation. I agree to release, indemnify and hold harmless all persons and other entities (third parties) providing the information requested by the Company. I also agree to release, indemnify and hold harmless the Company from any and all liability in connection with its conducting such investigation as it deems appropriate and the use of the information received from Third Parties.

I understand that if am hired, my employment with the Company may be terminated, with or without cause, at any time at the discretion of either the Company or myself. I understand that if I am accepted for employment with the Company, the Company reserves the right to change my job responsibilities, wages, benefits and any other term or condition of my employment with the Company at any time to meet the needs of the Company, subject to applicable federal and state laws.

This employment application is used to notify me that the nature and scope of an investigation, if one is conducted, could include such general identification information as residence verification, and, as applicable, information concerning my employment, education, credit record, general reputation, character, personal characteristics, and habits, and such information may be developed through personal interviews with third parties such as family members, neighbors, friends, associates, former employers, financial sources and custodians of official records. Only job related information developed from such a report will be considered in evaluating my employment application or continued employment.

I release this Company from all liability for damages from issuing truthful information and authorize any and all listed references, former schools, employers and their agents and employees to provide truthful information regarding my employment, character and qualifications.

By entering my name and today's date below and submitting this form, I am indicating that I have read the above statement and understand its content, intent and terms.

 
Name: (First MI. Last)
     		Date Today: