Application For Employment

TO APPLICANT: We deeply appreciate your interest in our organization. Thank you for taking the time to complete this application. The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law also prohibits other types of discrimination such as age, citizenship, disability, veteran status, attainment of benefits, and participation in union activities. The laws of most states and many localities also prohibit some or all of the above types of discrimination as well as some additional types including, but not limited to, discrimination based upon ancestry, marital status, parental status, sexual orientation, or source of income. The Fair Credit Reporting Act imposes restrictions with respect to information obtained from a consumer reporting agency, including but not limited to information regarding credit data, personal character, general reputation and mode of living. This list, however, is not exhaustive of the grounds on which discrimination is prohibited.

Personal

Date:
Position Applying For:

Last Name:
First Name:
Middle:

City: State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPALAUPennsylvaniaPUERTO RICORhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code:
Phone:

Email address:

Are you legally eligible for employment in the United States? YesNo

If hired, you are required to submit proof of your eligibility to work in the USA.

Are you over the age of eighteen? YesNo
If no, hire is subject to verification that you are of minimum legal age.

Were you previously employed by us? YesNo
If yes, when?

If your application is considered favorably, on what date will you be available for work?

Are there any other job-related experiences, skills, or qualifications which will be of special benefit in the job for which you are applying?

EMPLOYER 1
Company name: ,
address:
phone:
type of business:

From: To:
Weekly Starting Salary:
Weekly Last Salary:
Reason for leaving:
Describe the work you did:
Supervisor name:

EMPLOYER 2
Company name: ,
address:
phone:
type of business:

From: To:
Weekly Starting Salary:
Weekly Last Salary:
Reason for leaving:
Describe the work you did:
Supervisor name:

EMPLOYER 3
Company name: ,
address:
phone:
type of business:

From: To:
Weekly Starting Salary:
Weekly Last Salary:
Reason for leaving:
Describe the work you did:
Supervisor name:

---

Education

Elementary

Name and Address of Elementary School:
Last year completed: 5678
Did you graduate? YesNo

High School

Name and Address of High School School:
Last year completed: 1234
Course of Study:
Did you graduate? YesNo
List Degree or Diploma:

College

Name and Address of College School:
Last year completed: 1234
Course of Study:
Did you graduate? YesNo
List Degree or Diploma:

Other

Name and Address of Other School:
Last year completed: 1234
Course of Study:
Did you graduate? YesNo
List Degree or Diploma:

---

Personal References

Reference 1:
Name and Occupation:
Address:
Phone:

Reference 2:
Name and Occupation:
Address:
Phone:

Reference 3:
Name and Occupation:
Address:
Phone:

---

May we telephone you to follow up on this application? YesNo
If yes, what is the best time to call?
May we telephone you to follow up on this application at work?YesNo
If yes, what is the best time to call?
What is your business telephone number?

Please leave this field empty.

PLEASE READ

The facts set forth in my application for employment are true and complete. I understand that if employed, any false statement on this application may result in my dismissal. I furtherunderstand that this apploication is not and is not intended to be a contract of employment, nor does this application obligate the employer in any way if the employer decides toemploy me. I understand and agree that my employment is at-will and can be terminated be either party with or without notice, at any time, for any reason or no reason. NO one otherthan an officer of the Company has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing andthen only in a writing signed by an officer

Digital Initials:
[wphc]