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South Burlington Employment Application
Name_____________________________________________________________________________________
Address___________________________________________________________________________________
Telephone #_____________________________Cellular Phone #________________________________
E-mail Address_____________________________________________________________________________
Position(s) applied for________________________________________________________________________
Referral Source (e.g., Walk-in, Job Posting, Company’s Website, etc.) _________________________________
Best time to call you is? ________________________
May we contact you at work? ___ Yes ___ No
If yes, work number and best time to call:
Work number_________________________ time _______________
If you are under 18 and it is required,
Can you furnish a work permit? ____N/A ___ Yes ___ No
If no, please explain: ________________________________
Have you submitted an application here before? ____ Yes ____ No
If yes, give date(s) and position(s): ___________________________________________________
Have you ever been employed here before? ____ Yes ____ No
If yes, give dates: From_____________ To_______________
Is this application a request for reemployment following an extended military leave of absence from this
company? ____ Yes ____ No If yes, additional information may be requested.
Equal access to programs, services and employment opportunities is available to all persons without regard to race, color, religion, national origin, sex (including
pregnancy), sexual orientation, gender identity, ancestry, place of birth, age, physical or mental condition, genetic information, or any other basis protected by
federal, state, and/or local law.
In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the
application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include making a change to the
application process; providing written materials in an alternate format such as braille, large print, or audio recording; using a sign language interpreter; using
specialized equipment; or modifying testing conditions.
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Are you lawfully authorized to work in the United States? ____ Yes ____ No
When are you able to start working? _________________
Type of employment desired: ___Full-Time ___ Part-Time ____ Seasonal ____Temporary
Will you relocate if job requires it? ____ Yes ____ No Will you travel if job requires it? ___ Yes ____ No
Will you work overtime if required? ____Yes ____ No If no, please explain: ______________________________________
Are you able to perform the “essential functions” of the job for which you are applying (with or without
reasonable accommodation)? This question is not designed to elicit information about an applicant's disability. Please do not provide information
about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent
permitted by law.
____Yes ____No ____Need more information about the “job’s essential” function to respond
Driver’s license number required if driving may be required in the job for which you are applying:
____________________________ State___________
Have you ever been bonded? ____Yes ____No
Have you entered into an agreement with any former employer or other party (such as a noncompetition
agreement) that might, in any way, restrict your ability to work for our company? ____ Yes ____No
If yes, please explain: ____________________________________________________________________
Explain any gaps in your employment, other than those due to personal illness, injury, or disability?
__________________________________________________________________________________________
__________________________________________________________________________________________
If not addressed on previous page, have you ever been fired or asked to resign from a job? ___Yes ____No
If yes, please explain _________________________________________________________________________
__________________________________________________________________________________________
Skill and Qualifications
Summarize any special training, skills, languages, licenses, and/or certificates that may assist you in performing
the position for which you are applying:
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
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Computer Skills
Word Processing
Spreadsheet
Presentation
E-Mail
Internet
Other _______________________
_________________________________________________________________________________________
Employment History
Employer
Dates of employment
Position/Title
Address
Reason for leaving
Supervisor
Employer
Dates of employment
Position/Title
Address
Reason for leaving
Supervisor
Employer
Dates of employment
Position/Title
Address
Reason for leaving
Supervisor
Employer
Dates of employment
Position/Title
Address
Reason for leaving
Supervisor
_________________________________________________________________________________________
Educational Background
School (include city and state) # years complete Degree earned
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References
Name Title Relationship to you Phone number E-Mail
Related Information
When answering these questions, please exclude any information that would reveal race, color, religion, national origin, sex
(including pregnancy), sexual orientation, gender identity, ancestry, place of birth, age, physical or mental condition, genetic
information, or other similarly protected status.
To what job-related organizations (professional, trade, etc.) do you belong?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List special accomplishments, publications, awards, etc.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List any relevant volunteer work.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Is there any other job-related information you want us to know about you?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Applicant Statement
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete, and correct.
I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal
and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by
me in this application, resumé, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or
representatives, for seeking, gathering, and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons,
corporations, or organizations for furnishing such information about me.
I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating
any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law.
I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment.
My personal information may be shared with the employer’s affiliate(s) and third parties engaged by the employer to perform services for the employer. Any
personal information shared with an affiliate or third party is to be used solely to perform the services requested by the employer.
This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding
an applicant from consideration for employment on the basis of his or her race, color, religion, national origin, sex (including pregnancy), sexual orientation, gender
identity, ancestry, place of birth, age, physical or mental condition, genetic information, or any other protected status under applicable federal, state, or local law.
I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) eliminate me
from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.
Do not sign until you have read the above applicant statement.
I certify that I have read, fully understand and accept all term of the foregoing Applicant Statement
_________________________________________________________ ___________________________
Signature of Applicant Date
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