Employment Application Position Applied for*Date of Application* Date Format: 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Phone Type*CellHomeWorkBest time to call?PhonePhone TypeCellHomeWorkBest time to call?May we contact you at work?YesNoIf under 18, can you furnish a work permit?YesNoHave you filed an application here before?YesNoDate Date Format: MM slash DD slash YYYY Have you been employed here before?YesNoDate Date Format: MM slash DD slash YYYY Are you legally eligible for employment in this country?*YesNo(Proof of US Citizenship or immigration status will be required upon employment.)Date available for work:* Date Format: 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?*YesNoWill you work overtime if required?*YesNoWill you relocate if job requires it?*YesNoWill you travel if job requires it?*YesNoHave you ever been bonded?*YesNoHave you been convicted of a felony in the last 7 years?*YesNo(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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Educational BackgroundGrade SchoolName/AddressDate of attendance: From Date Format: MM slash DD slash YYYY Date of attendance: To Date Format: MM slash DD slash YYYY Did you graduate?Last grade completedCumulative GPACourse of study or degree completedHigh SchoolName/AddressDate of attendance: From Date Format: MM slash DD slash YYYY Date of attendance: To Date Format: MM slash DD slash YYYY Did you graduate?Last grade completedCumulative GPACourse of study or degree completedCollegeName/AddressDate of attendance: From Date Format: MM slash DD slash YYYY Date of attendance: To Date Format: MM slash DD slash YYYY Did you graduate?Last grade completedCumulative GPACourse of study or degree completedBusiness SchoolName/AddressDate of attendance: From Date Format: MM slash DD slash YYYY Date of attendance: To Date Format: MM slash DD slash YYYY Did you graduate?Last grade completedCumulative GPACourse of study or degree completedOtherName/AddressDate of attendance: From Date Format: MM slash DD slash YYYY Date of attendance: To Date Format: MM slash DD slash YYYY Did you graduate?Last grade completedCumulative GPACourse of study or degree completedScholarships, Honors, Etc.Extracurricular ActivitiesCourses related to position desired or special skillsReferencesList 3 individuals who have knowledge of your occupational skills and/or background who are not related to you and are not previous supervisors.NameAddressOccupationTelephoneYears KnownNameAddressOccupationTelephoneYears KnownNameAddressOccupationTelephoneYears KnownList 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.)OrganizationOffices HeldOrganizationOffices HeldOrganizationOffices HeldOrganizationOffices HeldOrganizationOffices HeldOrganizationOffices HeldList 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 Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Company or OrganizationCityPhoneNumber of people supervisedSupervisorReason for LeavingSalary - startingSalary - lastDescription of duties/job title (if sales, also give area covered)From Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Company or OrganizationCityPhoneNumber of people supervisedSupervisorReason for LeavingSalary - startingSalary - lastDescription of duties/job title (if sales, also give area covered)From Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Company or OrganizationCityPhoneNumber of people supervisedSupervisorReason for LeavingSalary - startingSalary - lastDescription of duties/job title (if sales, also give area covered)From Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Company or OrganizationCityPhoneNumber of people supervisedSupervisorReason for LeavingSalary - startingSalary - lastDescription of duties/job title (if sales, also give area covered)From Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Company or OrganizationCityPhoneNumber of people supervisedSupervisorReason for LeavingSalary - startingSalary - lastDescription of duties/job title (if sales, also give area covered)Additional information necessary for a complete presentation of your qualificationsMilitaryBranch of US ServiceMajor DutiesMilitary Schools AttendedMilitary Job ExperienceEmployer 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* Date Format: MM slash DD slash YYYY Signature*JobJob Preference in OrderIt 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* Date Format: 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.
