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Employment Application

General

Name *

First

Middle

Last

Date of Birth *

SSN *

Day Phone No. *

Night Phone No. *

Email *

Present Address *

Years at Present Address *

Previous Address *

Years at Previous Address *

Mailing Address *

Are you 18 years or older? *

Yes
No

The age Discrimination in Employment Act of 1987 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

If hired, can you provide proof of citizenship or legal right to work in the United States? *

Yes
No

Have you ever plead guilty (including Deferred Adjudication) or been convicted of any criminal offense, other than minor traffic citations? If yes, please explain in the message box below. *

Yes
No

Explain (if you answered yes to the question above):

Position

Position Applied For *

Source of Referral

Date *

Position Desired *

Full-Time
Part-Time

Salary Expected *

Mon. (availability) *

If you are available to work all day and all night shifts just put "all" within the time slots.

Tues. (availability) *

If you are available to work all day and all night shifts just put "all" within the time slots.

Wed. (availability) *

If you are available to work all day and all night shifts just put "all" within the time slots.

Thurs. (availability) *

If you are available to work all day and all night shifts just put "all" within the time slots.

Fri. (availability) *

If you are available to work all day and all night shifts just put "all" within the time slots.

Sat. (availability) *

If you are available to work all day and all night shifts just put "all" within the time slots.

Sun. (availability) *

If you are available to work all day and all night shifts just put "all" within the time slots.

Employment History

Most Recent Employer

Employer's Address

Phone Number

Supervisor's Name

Start Date

End Date

Position Title

Final Salary

Reason For Leaving

Previous Employer

Employer's Address

Phone Number

Supervisor's Name

Start Date

End Date

Position Title

Final Salary

Reason For Leaving

Previous Employer

Employer's Address

Phone Number

Supervisor's Name

Start Date

End Date

Position Title

Final Salary

Reason For Leaving

Please list below any other work experience relevant to this position and explain any gaps in employment history:

Education and Training

Graduated High School *

Yes
No

Type of Degree or Certificate

School Name and Address

Graduated University or Technical School? *

Yes
No

Type of Degree or Certificate

School Name and Address

Do you have a valid Driver's License? *

Yes
No

Language Ability

Are you bilingual? *

Yes
No

Please list a language that you can use at work: *

Speak *

Yes
No

Read *

Yes
No

Write *

Yes
No

Please list a language that you can use at work:

Speak

Yes
No

Read

Yes
No

Write

Yes
No

Skills

Computer Software Skills

Office Machinery Skills

Months of Cash Handling

Other

References

Name/Title

Reference 1

Mailing Address

Phone

Name/Title

Reference 2

Mailing Address

Phone

Name/Title

Reference 3

Mailing Address

Phone

Authorization

Digital Signature *

I HEREBY AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU. I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR TERMINATION. I UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINED TIME PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT ANY PRIOR NOTICE.

Date *

NO PERSON SHALL BE DENIED EMPLOYMENT ON THE BASIS OF RACE, COLOR, ETHNICITY, NATIONAL ORIGIN, SEX/GENDER, SEXUAL ORIENTATION, RELIGION, CREED OR DISABILITY EMPLOYMENT IS CONTINGENT UPON FURNISHING EVIDENCE OF IDENTITY AND EMPLOYMENT ELIGIBILITY

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