Applicant Name: Date:
Position(s) applied for or type of work desired:
Telephone #: Social Security #:
Type of employment desired:Full-timePart-timeTemporary
Date you will be available to start work:
Are you able to meet the attendance requirements? YesNo
Do you have any objection to working overtime if necessary? YesNo
Can you travel if required by this position? YesNo
Have you ever been previously employed by our organization? YesNo
Can you submit proof of legal employment authorization and identity? YesNo
If you are under 18, can you furnish a work permit if it is required? YesNo

Driver's license number (if driving is an essential job duty):
How were you referred to us?

Please provide all employment information for your past three employers starting with the most recent.

Employer: Position held:
Address: Telephone #:
Immediate Supervisor and title:
Dates employed from: to Salary:
Job Summary:
Reason for leaving:


Summarize any job-related training, skills, licenses, certificates, and/or other qualifications:

List school name and location, years completed, course of study, and any degrees earned:
High school:
Technical Training:

List 3 references names, telephone numbers, and years known (do not include relatives or employers):

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application
from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering,
and using such information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination
of employment if I am employed, whenever it may be discovered.

If I am employed I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly,
either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons
need for a reasonable accommodation as required by the ADA.

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to
submit such proof within the required time shall result in immediate termination of employment.

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.