Employment Application Form

Applicant Information
Applicant Name____________________
Current Address____________________
City___________ State____________ Zip_______
Email Address______________________________________________________
Home Phone___________________ Cell Phone_______________________
How were you referred to our Company?
_____________________________________________________________________________________
________________________________________________________________.

Education, Training and Experience

High School:
School Name______________________________________________
School Address______________________________________________________
City_________________ State______________

Zip______

Number of Years Completed__________

Graduated [ ] yes [ ] no
Degree or Diploma earned_____________________

College/ University:
School Name_______________________________________
School Address_____________________________________________________________
City________________ State_______________ Zip_______
Number of Years Completed________
Graduated? [ ] yes [ ] no
Degree / Diploma earned? ______________________________________

Military
Branch: _________________________________
Rank in Military: __________________
Total Years: ____________
Skills/ Duties:
____________________________________________________________________________
Do you speak, write or understand any foreign languages? [ ] yes [ ] no
If yes, what languages can you speak?
__________________________________________________________________________________
Do you have any other experiences, training, qualifications, or skills which you feel free to bring to our
attention? [ ] yes [ ] no
If yes, please explain____________________________________________________________________.

Personal Information:
Have you ever applied to/ worked for a Company before? [ ] yes [ ] no
If yes, please explain (include the date):___________________________________________________
Do you have any friends, relatives, or acquaintances working for Company? [ ] yes [ ] no
If yes, state their name & relationship______________________________________________________
If hired, would you have transportation to/from work? [ ] yes [ ] no
Are you over the age of 18? [ ] yes [ ] no
If you are under the age of 18 hire is subjected to verification of minimum legal age.
If hired, would you be able to submit to and pass a controlled substance text? [ ] yes [ ] no
Are you able to present evidence of your U.S citizenship or proof of your legal right to work in the
United States? [ ] yes [ ] no
Are you able to perform the essential functions of the job of which you are applying, either with/
without reasonable accommodations? [ ] yes [ ] no
If no, describe the functions that cannot be performed_______________________________________
Have you ever been convicted of a crime? [ ] yes [ ] no
If yes, please describe the crime___________________________________________________________

Employment History:
Are you currently employed? [ ] yes [ ] no
If you are currently employed, may we contact your current employers? [ ] yes [ ] no
Below please describe past and present employment positions, dating back five years. Please account
for all periods of unemployment. Even if you have attached your resume to this section.
Name of Employer___________________________________
Name of Supervisor________________________________________
Telephone Number____________________________
Business Type ___________________________________________________
Address______________________________________________________________________________
City ______________________________ State______ Zip ___________
Length of Employment ____________________________________________________
Position & Duties______________________________________________________________________
Reason for Leaving________________________________________________________________
May we contact this employer for references [ ] yes [ ] no

Name of Employer: _________________________________________________

Name of Supervisor: ____________________________________
Telephone Number: _________________________
Business Type: _____________________________________________________________
Address: _________________________________________________________________________
City _________________________ State_____ Zip ______________
Length of Employment: ___________________________________________________________
Position & Duties ___________________________________________________________
Reasoning for Leaving: ___________________________________________________________
May we contact this for references? [ ] yes [ ] no

Name of Employer: _________________________________________________

Name of Supervisor: ____________________________________

Telephone Number: _________________________

Business Type: _____________________________________________________________
Address: _________________________________________________________________________
City _________________________ State_____ Zip ______________
Length of Employment: ___________________________________________________________
Position & Duties ___________________________________________________________
Reasoning for Leaving: ___________________________________________________________
May we contact this for references? [ ] yes [ ] no

Are you applying for:

Temporary work- such as summer or holiday work? [ ] yes [ ] no

Regular part- time work? [ ] yes or [ ] no
Regular full- time work? [ ] yes [ ] no
What days and hours are you available? ____________________________________
If applying for temporary work, when will you be available?
______________________________________________________________________________
___________________________________________________________________________
If hired, on what date can you start working? ___ / ___ / ___
Can you work on weekends? [ ] yes [ ] no
Can you work in the evenings? [ ] yes [ ] no
Are you available to work overtime? [ ] yes [ ] no
Salary Desired: $_______________________________________________

Employment Positions:
Position(s) applying for:
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________________________

References:
Name First, Last: ___________________________________________________________________
Telephone Number: _________________________________
Address: ____________________________________________________________________________

City: _________________________

State: _________________ Zip: __________

Occupation: __________________________________________________________________________
Number of Years Acquainted: ____________

Name- First, Last _____________________________________________________________

Telephone Number: ______________________________________
Address: ____________________________________________________________________________
City: _________________________

State: _________________ Zip: __________

Occupation: __________________________________________________________________________
Number of Years Acquainted: ____________

Name- First, Last _____________________________________________________________

Telephone Number: ______________________________________
Address: ____________________________________________________________________________
City: _________________________

State: _________________ Zip: __________

Occupation: __________________________________________________________________________
Number of Years Acquainted: ____________

Please Read and Initial Each Paragraph, then Sign Below

I certify that I have not purposely withheld any information that might adversely affect my chances for
hiring. I attest to the fact that the answers given by me are true & correct to the best of my knowledge
and ability. I understand that any omission of material fact on this application or on any document used
to secure can be grounds for rejection of application or, if I am employed by this company, terms for my
immediate expulsion from the company.
_______

I understand that if I am employed, my employment, is not definite and can be terminated at any time
either with or without prior notice, and by either me or the company.
______

Applicants Signature: _____________________________________________

Date: ________________________