Application for Employment

Personal Information

Date:
Name Last:
First:
Middle:
Present Address, Street:
City:
State:
Zip:
Permanent Address, Street:
City:
State:
Zip:
Phone Number:
Are you under 18 years of age?
Yes No
If yes, list birth date
Have you ever been employed by this company before?
Yes No
Where?
When
Manager's Name
Are you eligible to work in the United States?
Yes No
If hired do you have a reliable means of transportation to get to work?
Yes No
Explain:
What interests, hobbies, or extra curricular activities do you have (exclude those that are religious or ethnic in nature):
Have you ever been convicted of a felony or misdemeanor other than a traffic violation?
Yes No
If yes, explain:

Employment Desired

Position applying for:
Full or Part Time
Date available:
Rate of pay desired:

Please indicate below the days and hours on those days that you would be available to work:

Monday
Yes No
Hours:
Tuesday
Yes No
Hours:
Wednesday
Yes No
Hours:
Thursday
Yes No
Hours:
Friday
Yes No
Hours:
Saturday
Yes No
Hours:
Sunday
Yes No
Hours:

Employment History

(List below former employers, starting with last one first)
From:
To:
Employer's Name, Address
Supervisors Name/Phone
Job Title and Duties
Salary/Wage
Reason for Leaving

From
To
Employer's Name, Address
Supervisors Name/Phone
Job Title and Duties
Salary/Wage
Reason for Leaving

From:
To:
Employer's Name, Address
Supervisors Name/Phone
Job Title and Duties
Salary/Wage
Reason for Leaving

From:
To:
Employer's Name, Address
Supervisors Name/Phone
Job Title and Duties
Salary/Wage
Reason for Leaving
May we contact the past and/or present employers listed above?
Yes No
If no, then indicate those you do not want us to contact.

IN CASE OF EMERGENCY, NOTIFY:

Name:
Address:
Phone Number:

Education

High School
Grade
Year
GPA
Graduate
Yes No

College
Grade
Year
GPA
Graduate
Yes No

Trade/Business
Grade
Year
GPA
Graduate
Yes No

Other (specify)
Grade
Year
GPA
Graduate
Yes No

References

Give the names of persons not related to you as references, whom you have known at least 1 year

Name
Address
Phone Number
Years Acquainted
Personal/Business

Name
Address
Phone Number
Years Acquainted
Personal/Business

Name
Address
Phone Number
Years Acquainted
Personal/Business

Are you known to schools/references by another name?
Yes No
If yes, please indicate the name(s):

1.I authorize investigation of all statements contained on this application except where I have requested on this form that no investigation be made.

2.I understand that misrepresentation of omission of facts called for is cause for dismissal and that my employment is substantially dependent on truthful answers to the foregoing inquires.

3.I understand that nothing contained in this employment application or in the granting of an interview is intended to nor does it create an employment contract between the company and myself for either employment or the providing of any benefit. In the event that an employment relationship is established, I understand that I have the right to terminate my employment at any time for any reason or no reason, and the Company retains the same right regarding the discontinuation of my employment.

Signature:

Type Name:
Date: