Employment Form

Employment Application

Personal Information

Name (Last, First, MI)

Street Address

City, State, Zip

Home phone number

Work phone number

Facsimile number

Cell phone number

Email address

Employment Desired

Position applied for

How did you hear about this position?

Date available for work

Desired hours (full time, part time, etc.)

Education

	Name and Address of School	Course of Study	Total Years of Study	Degree/ Diploma
High School
Undergraduate College
Graduate/ Professional
Other (Specify)

List any seminars, classes or other education not listed above which may help qualify you for this position:

Employment History

List below all present and past employers over the past ten years, starting with the most recent employer. Account for all periods of unemployment. You must complete this section even if sending a resume.

1.	Employer	Start Date	Supervisor
	Address	End Date	Phone number
	City, State, Zip	Salary	Job position
	Reason(s) for leaving
2.	Employer	Start Date	Supervisor
	Address	End Date	Phone number
	City, State, Zip	Salary	Job position
	Reason(s) for leaving
3.	Employer	Start Date	Supervisor
	Address	End Date	Phone number
	City, State, Zip	Salary	Job position
	Reason(s) for leaving
4.	Employer	Start Date	Supervisor
	Address	End Date	Phone number
	City, State, Zip	Salary	Job position
	Reason(s) for leaving
5.	Employer	Start Date	Supervisor
	Address	End Date	Phone number
	City, State, Zip	Salary	Job position
	Reason(s) for leaving

Additional Information
Identify formal job training that relates to this position: Identify what skills or certification you possess related to this position:
If you are hired, what value would you add to ourcompany?
Do you have any friends or relatives employed by this company?		Yes No
If Yes, please provide their names and relationship to you:
Are you currently employed?		Yes No
May we contact your employer?		Yes No
Are you currently on "lay off" status and subject to recall?		Yes No
If you are under 18 years of age, can you provide proof of your eligibility to work?		Yes No
If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.?		Yes No
If hired, do you have a reliable means of transportation to and from work?		Yes No
Have you ever been convicted of a felony or misdemeanor?		Yes No
If Yes, please explain:
References List below three persons not related to you who have knowledge of your work performance within the last 5 years
Name		Occupation
Company name	Address
Telephone	E-mail	Relationship & years acquainted

Name		Occupation
Company name	Address
Telephone	E-mail	Relationship & years acquainted

Name		Occupation
Company name	Address
Telephone	E-mail	Relationship & years acquainted

Additional space provided to expand on any points or questions asked previously in this application
Please read each statement closely and check each acknowledging your understanding
Agree Disagree	Equal Employment Opportunity Statement This company is committed to the principles of equal employment opportunity and is committed to make employment decisions based on merit. We are committed to complying with all Federal, State and local laws providing for equal employment opportunities, as well as all laws related to terms and conditions of employment. The Company desires to maintain a work environment that is free of sexual harassment and discrimination due to race, religion, color, national origin, physical or mental disability, age or any other status protected by Federal, State or local laws. The Company will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless undue hardship would result for the company.
Agree Disagree	Discrimination and Sexual Harassment Policy Statement This Company will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline, up to and including termination. Prohibited sexual harassment is defined as follows: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct is made whether explicitly or implicitly a term or condition of an individual’s employment; (2) Submission to or action of such conduct by an individual is used as the basis for employment decisions affecting such individuals; or (3) Such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive work environment.
Agree Disagree	Complete and Accurate Information I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application, or any other document used to secure employment, shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
Agree Disagree	Investigation Authorization I authorize investigation into all statements and references contained in this application.
Agree Disagree	Company Obligation I understand and agree that the Company’s acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the company has agreed to hire me. I understand that the Company is under no obligation to hire me as the result of accepting this completed application.
Agree Disagree	I HAVE READ AND UNDERSTAND THE ABOVE POLICY STATEMENTS AND AGREE TO BE BOUND BY THEM IF EMPLOYED BY THE COMPANY.