Employment Form

Applicants are considered without regard to race, color, religion, sex, national origin, age, disability, sexual orientation and gender identity or any other prohibited basis of discrimination, as provided under applicable state and federal law.

Name:	Address:
City:	State:
Zip:	Phone:
Email Address:	Social Security Number:
Date of application:	Position Applied For:
Referral Source:  Advertisement Friend Employee Relative Walk-In Private Agency Other
Name of Source (if applicable):

Have you ever been employed here before? Yes No	If yes, give date
Are you employed now?  Yes No	May we contact your present employer?  Yes No
May we contact you at work?  Yes No	If yes, work number
Best Time to Call:
On what date would you be available for work?	Expected salary:
Are you available to work: Full-time Part-time Temporary
Will you work overtime if required  Yes No
List professional, trade, business or civic activities and offices held. (You may exclude those which indicate race, color, religion, sex, age, national origin, disability).

EDUCATION

EMPLOYMENT EXPERIENCE
Start with your present or last job and include employment for the last 10 years. Include military service assignments and volunteer activities. Exclude organization names which indicate, for example, race, color, religion, sex, age, disabilit y or national origin.

 

Note: Please only upload pdf, word doc, or image files.

REFERENCES
List Names and telephone number of three business/work references who are not related to you and are not previous supervisors . If not applicable, list three school or personal references who are not related to you

State any additional information you feel may be helpful to us in considering your application or comments.

APPLICANT'S STATEMENT

I understand and agree that any misrepresentation by me in this application will be sufficient cause for rejection of this application and/or termination of employment if I am hereafter employed by the Company. Furthermore, if I am hired, I understand that I am free to resign at any time, and that the Company reserves the right to terminate my employment at any time, with or without cause, and without prior notice. I understand that no such employment relationship must be made in writing and signed by an authorized representative of the Company. I understand that if you make an offer of employment to me it may be a conditional offer of employment. I may be required to submit to a pre-employment medical exam, to provide information in response to your medical inquiries, the results of which might disqualify me from employment. If requested, I agree to furnish such information and to submit to such examinations. I understand that I may be requested to submit to a test to detect the current illegal use of drugs, and if the test results identify that I am a current illegal use of drugs I will not be eligible for employment by the Company. I further understand that I have the right to refuse to s ubmit to such tests of my own free will. I authorize the Company to make a thorough investigation of my past employment, education and job-related activities. To the extent permitted by law , I release the Company from any liability which might result from making such investigation and I also release from any liability all persons and entities supplying such inf ormation. I acknow ledge that the Company is an equal opportunity employer and that the Company does not discriminate in employment. I understand that no question on this application is used for the purpose of limited or excluding the Company's consideration of me for employment on a basis prohibited by federal, state or local law , nor is it used by the Company for the purpose of attempting to obtain information prohibited by federal, state or local law . I understand that the Company will consider this application to contain current information for a period of only sixty (60) days. At the expiration of sixty (60) days, if I have not heard from the Company and if I still desire to be considered for employment I understand that it will be necessary for me to complete new application.

Print Name:	Signature: