Application For Employment

Last Name:

First Name:

Middle:

Address:

City:

State:

Zip Code:

Email Address:

Phone:

Position Applied For:

Shift Preferred:

1     2     3     Any

Special training or skills (languages, machine operation, etc.) that would benefit you in the job for which you are applying:

Would you accept full-time-work?

Yes     No

Would you accept part-time-work?

Yes     No

On what date would you be available for work?

Have you ever been employed here?

Yes     No

If yes, dates?

Are you lawfully authorized to work in the united states?

Yes     No

If you are under 18 years old, can you furnish a work permit if required?

NA     Yes     No

Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)?

This question is not designed to elicit information about an applicant's disability. Please do not supply information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Yes     No     Need more information about the job's essential functions to respond.

Educational Background

Starting with the school you most recently attended, provide the following information.

Employment History

Starting with your most recent employer, provide the following information. You may include any verified work performed on a volunteer basis.

Employer:

Telephone #:

Address:

City:

State:

Zip Code:

Starting Job Title / Final Job Title:

Dates Employed:

Immediate Supervisor and Title (for most recent position held):

May We Contact For Reference?: Yes    No    Later

E-mail:

Summarize the type of work performed and job responsibilities.

Employer:

Telephone #:

Address:

City:

State:

Zip Code:

Starting Job Title / Final Job Title:

Dates Employed:

Immediate Supervisor and Title (for most recent position held):

May We Contact For Reference?: Yes    No    Later

E-mail:

Summarize the type of work performed and job responsibilities.

Employer:

Telephone #:

Address:

City:

State:

Zip Code:

Starting Job Title / Final Job Title:

Dates Employed:

Immediate Supervisor and Title (for most recent position held):

May We Contact For Reference?: Yes    No    Later

E-mail:

Summarize the type of work performed and job responsibilities.

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete, and correct.

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 educational 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, its agents, employees, or representatives, for seeking, gathering, and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law.

I understand that this application remains current for only 60 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 for me 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 with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notic, except as may be required 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 companies president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer's affiliate(s) and third parties engaged by the employer to perform services for the employer. Any personal information shared with an affiliate or third party is to be used solely to perform the services requested by the employer.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex (including pregnancy), race, color, religion, national origin, citizenship, age, disability, genetic information, or any other protected status under applicable federal, state of local law.

Mandatory Employer Disclosures

Notice to Maryland Applicants: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100. Notice to Massachusetts applicants: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. Notice to Rhode Island applicants: This company complies with Rhode Island law prohibiting smoking in enclosed areas within places of employment. Notice to North Dakota applicants: This company complies with North Dakota law prohibiting smoking within 20 feet of entrance and inside places of employment. Notice to Indiana applicants: This company complies with Indiana law prohibiting smoking in enclosed areas within places of employment.

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) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPICANT STATEMENT.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

IF YOU ARE INVITED TO INTERVIEW FOR THIS JOB, YOU WILL BE REQUESTED TO SIGN THIS APPLICATION

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