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Employment Application Form

March 10, 2008

This Employment Application form is used to capture a prospective employee’s personal and professional information at a glance. It seeks the name, address, type of work desired, previous work experience, military service history, education, and references. It states that the Company may conduct a background investigation,and releases the Company from any liability resulting from such investigation. It also states that there may be a drug and/or alcohol test as a condition of employment. The employment application will remain active for a period of only 90 days. It requires the prospective employee’s signature.

Application For Employment

[Company name] is an equal opportunity employer and does not discriminate on the basis of race, religion, color, national origin, age, sex, gender, disability, or any other characteristic protected by law.

Introduction Information:

Name:______________________________________________________

Date:______________

Address:_______________________________________________________________________

City:______________________ State:________ ZIP ___________

Phone:______________

Applicant Questions:

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If hired, can you provide documents required to establish your eligibility to work in the U.S.? ____Yes ____No

Are you 16 years of age or older? ____Yes ____No

How were you referred to [Company Name]? _________________________________________

Have you ever been convicted of, or pled guilty to, or no contest to a crime other than a minor traffic violation?
__ Yes __No

If Yes, please explain in detail on a separate piece of paper and include the date of final disposition of the case and the nature of the offense. This information will not necessarily disqualify you from employment, but false or misleading information will. Factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account.

Education:

High School or last grade completed:

Name & Address of School: _______________________________________________________ Course of Study: _________________________ Number of years completed: ______________ Degree/Diploma: ________________________________________________________________

College or Technical School

Name & Address of School: _______________________________________________________ Course of Study: ___________________________Number of years completed:______________ Degree/Diploma:________________________________________________________________

Other Schooling or Training

Name & Address of School:_______________________________________________________ Course of Study: _________________________ Number of years completed: ______________ Degree/Diploma: ________________________________________________________________

Military Experience:

Branch of Service: ________________________________ From: __________ To: ___________ Rank/Type of Service: ___________________________________________________________ Special Training/Experience: ______________________________________________________

Record of Employment:

List positions starting with most recent:

Employer: _______________________________ Telephone:____________________________ Address: ______________________________________________________________________ Position Title: ___________________________ Supervisor:_____________________________ Start Date: ________ Date Left: ________ Beginning Salary: _______ Ending Salary:________ Duties:________________________________________________________________________ Reason for Leaving: _____________________________________________________________

Employer: _______________________________ Telephone:____________________________ Address: ______________________________________________________________________ Position Title: ___________________________ Supervisor:_____________________________ Start Date: ________ Date Left: ________ Beginning Salary: _______ Ending Salary:________ Duties:________________________________________________________________________ Reason for Leaving: _____________________________________________________________

Employer: _______________________________ Telephone:____________________________ Address: ______________________________________________________________________ Position Title: ___________________________ Supervisor:_____________________________ Start Date: ________ Date Left: ________ Beginning Salary: _______ Ending Salary:________ Duties:________________________________________________________________________ Reason for Leaving: _____________________________________________________________

Work-Related References:

(Do not include relatives)

Type of worked desired:________________

Salary desired: ___________

Date Available:_______

NameOccupationYears KnownContact Information
1.________________________________________________________________________________
2.________________________________________________________________________________
3.________________________________________________________________________________

Statement:

(Please read this statement carefully before signing this application):

I understand that employment with [Company Name] (the Company) is at will, meaning that I or the Company may terminate my employment at any time or for any reason consistent with applicable state or federal law.

I authorize the Company to conduct a thorough background investigation of my work and personal history and verify all data given on this application and during interviews. I hereby release the Company, and its representatives or agents, from any liability that might result from such an investigation. I authorize all individuals, schools, and firms named to provide any requested information and release them from all liability for providing the requested information.

I understand that the Company requires the successful completion of a drug and/or alcohol test as a condition of employment.

I understand this application will be active for a period of 90 days; after that time, if I wish to be considered for employment, I must submit a new application. I certify that all the statements in this completed application are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal to hire.

Signature of Applicant: _________________________________________________________

Date Signed: _________________________________________________________


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