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Employment Application Encore Division*Office/AdminSalesDelivery, Forklift/Yard, or WarehouseInstallationPosition Applied for* Specific position if known, otherwise general position is fineDate of Application* MM slash DD slash YYYY Referral Source Advertisement Employee Relative Walk-in Government Employment Agency Private Employment Agency Other Name of Source (If Applicable) Name* First Middle Last Social Security Number* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Phone Type* Cell Home Work Best time to call? PhonePhone Type Cell Home Work Best time to call? May we contact you at work? Yes No If under 18, can you furnish a work permit? Yes No Have you filed an application here before? Yes No Date MM slash DD slash YYYY Have you been employed here before? Yes No Date MM slash DD slash YYYY Are you legally eligible for employment in this country?* Yes No (Proof of US Citizenship or immigration status will be required upon employment.)Date available for work:* MM slash DD slash YYYY Type of employment desired:* Full-Time Part-Time Temporary Seasonal Educational Co-op Are you on lay-off and subject to recall?* Yes No Will you work overtime if required?* Yes No Will you relocate if job requires it?* Yes No Will you travel if job requires it?* Yes No Have you ever been bonded?* Yes No Have you been convicted of a felony in the last 7 years?* Yes No (Such conviction may be relevant if job related, but does not bar you from employment.)If yes, please explain:*Driver's License Number: (if required by job)State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Educational BackgroundGrade SchoolName/Address Date of attendance: From MM slash DD slash YYYY Date of attendance: To MM slash DD slash YYYY Did you graduate? Last grade completed Cumulative GPA Course of study or degree completed High SchoolName/Address Date of attendance: From MM slash DD slash YYYY Date of attendance: To MM slash DD slash YYYY Did you graduate? Last grade completed Cumulative GPA Course of study or degree completed CollegeName/Address Date of attendance: From MM slash DD slash YYYY Date of attendance: To MM slash DD slash YYYY Did you graduate? Last grade completed Cumulative GPA Course of study or degree completed Business SchoolName/Address Date of attendance: From MM slash DD slash YYYY Date of attendance: To MM slash DD slash YYYY Did you graduate? Last grade completed Cumulative GPA Course of study or degree completed OtherName/Address Date of attendance: From MM slash DD slash YYYY Date of attendance: To MM slash DD slash YYYY Did you graduate? Last grade completed Cumulative GPA Course of study or degree completed Scholarships, Honors, Etc. Extracurricular Activities Courses related to position desired or special skills ReferencesList 3 individuals who have knowledge of your occupational skills and/or background who are not related to you and are not previous supervisors.Name Address Occupation Telephone Years Known Name Address Occupation Telephone Years Known Name Address Occupation Telephone Years Known List professional, trade, business or civic assocations and any offices held. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status.)Organization Offices Held Organization Offices Held Organization Offices Held Organization Offices Held Organization Offices Held Organization Offices Held List special accomplishments, publications and awards. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status.List special accomplishments, publications and awards. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status.Experience RecordList paid and volunteer experience as applicable, starting with the last (or present) place worked first. Account for the last 10 years (or all years worked if less than 10.)From MM slash DD slash YYYY To MM slash DD slash YYYY Company or Organization City PhoneNumber of people supervisedSupervisor Reason for Leaving Salary - startingSalary - lastDescription of duties/job title (if sales, also give area covered)From MM slash DD slash YYYY To MM slash DD slash YYYY Company or Organization City PhoneNumber of people supervisedSupervisor Reason for Leaving Salary - startingSalary - lastDescription of duties/job title (if sales, also give area covered)From MM slash DD slash YYYY To MM slash DD slash YYYY Company or Organization City PhoneNumber of people supervisedSupervisor Reason for Leaving Salary - startingSalary - lastDescription of duties/job title (if sales, also give area covered)From MM slash DD slash YYYY To MM slash DD slash YYYY Company or Organization City PhoneNumber of people supervisedSupervisor Reason for Leaving Salary - startingSalary - lastDescription of duties/job title (if sales, also give area covered)From MM slash DD slash YYYY To MM slash DD slash YYYY Company or Organization City PhoneNumber of people supervisedSupervisor Reason for Leaving Salary - startingSalary - lastDescription of duties/job title (if sales, also give area covered)Additional information necessary for a complete presentation of your qualificationsMilitaryBranch of US Service Major Duties Military Schools Attended Military Job Experience Employer may investigate my background and employment record. I authorize any person or company to furnish any information in their possession without liability. I certify that all statements made by me on this application are true.Name* Date* MM slash DD slash YYYY Signature*JobJob Preference in Order 2 3 4 It is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the Employer’s service if I have been employed. Furthermore, I understand that as I am free to resign at anytime, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary. I give the Employer the right to investigate all references and to secure additional information about me, if job related. I hearby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. The Employer is an Equal Opprtunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law. I certify that all statements made by me in this application are true.Signature*Date* MM slash DD slash YYYY PRE-EMPLOYMENT URINALYSIS CONSENT AGREEMENTPRE-EMPLOYMENT TESTING REQUIREMENTS: ALL JOB APPLICANTS TO WHOM A JOB OFFER HAS BEEN MADE WILL BE TESTED FOR THE USE OF CONTROLLED SUBSTANCES, AT EMPLOYER’S EXPENSE, AS A PRE-QUALIFICATION CONDITION BEFORE THEIR HIRING IS FINAL. THEREFORE, As a condition of my employment application, I consent to the urine sample collection and controlled substance testing. I understand a positive test for controlled substance(s) based on the urinalysis test will disqualify me from further job consideration with company. Negative and positive results will be reported to this company and maintained in a confidential file. My written authorization is required for the urinalysis test results to be given to other parties. I have read and understand the above conditions for the Pre-Employment Urinalysis Consent Agreement. I also agree to reimburse Employer for the testing fee if I do not complete the 120-day probationary period after my hire date. **A consent will be signed by applicant and witness at time of testing.Email (if you would like a copy of this application sent to you) Enter Email Confirm Email Δ
