Standard Application for Employment
It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex,
religion, national origin, disability or other protected classifications.
Please carefully read and answer all questions. You will not be considered for employment if you fail to completely answer all the questions
on this application. You may attach a résumé, but all questions
must be answered.
Employer”
Position applying for
PERSONAL DATA
Name (last, first, middle)
Street Address and/or Mailing Address
City
State
Zip
Home Telephone Number
Business Telephone Number
Cellular Telephone Number
Date you can start work
Do you have a High School Diploma or GED?
Yes No
POSITION INFORMATION Check all that you are willing to work
Hours: Full Time
Part Time
Days
Evenings
Swing
Graveyard
Weekends
Status: Regular
Temporary
Are you authorized to work in the U.S. on an unrestricted basis? Yes No
Have you ever been convicted of a felony? (Convictions will not necessarily disqualify an applicant for employment.) Yes No
If yes, explain:
Have you been told the essential functions of the job or have you been viewed a copy of the job description listing the essential functions of the job?
Yes
No
Can you perform these essential functions of the job with or without reasonable accommodation? Yes
No
QUALIFICATIONS Please list any education or training you feel relates to the position applied for that would help you perform the work, such as schools, colleges,
degrees, vocational or technical programs, and military training.
School Name
Degree
Address/City/State
School
School
Other
SPECIAL SKILLS List any special skills or experience that you feel would help you in the position that you are applying for (leadership, organizations/teams, etc.
REFERENCES Please list three professional references not related to you, with full name, address, phone number, and relationship. If you don’t have three
professional references, then list personal, unrelated references.
Name
Address/City/State
Phone
Relationship
WORK HISTORY
Start with your present or most recent employment and work back. Use separate sheet if necessary. (INCLUDE PAID AND UNPAID POSITIONS)
Job Title #1
Start Date (mo/day/yr)
End Date (mo/day/yr)
Company Name
Supervisor’s Name
Phone Number
City
State
Zip
Duties
:
Reason for Leaving
Starting Salary
Ending Salary
May we contact your present employer? Yes No N/A
Job Title #2
Start Date (mo/day/yr)
End Date (mo/day/yr)
Company Name
Supervisor’s Name
Phone Number
City
State
Zip
Duties
:
Reason for Leaving
Starting Salary
Ending Salary
Job Title #3
Start Date (mo/day/yr)
End Date (mo/day/yr)
Company Name
Supervisor’s Name
Phone Number
City
State
Zip
Duties:
Reason for Leaving
Starting Salary
Ending Salary
Job Title #4
Start Date (mo/day/yr)
End Date (mo/day/yr)
Company Name
Supervisor’s Name
Phone Number
City
State
Zip
Duties:
Reason for Leaving
Starting Salary
Ending Salary
I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am
employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the Employer to make an investigation of any of the facts
set forth in this application and release the Employer from any liability. The employer may contact any listed references on this application.
I acknowledge and understand that the company is an “at will” employer. Therefore, any employee (regular, temporary, or other type of category
employee) may resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or without cause, with
or without notice to the other party.
Applicant Signature Date
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