Application for Employment
We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on
this application is used for the purpose of limiting or excluding any applicant from consideration for
employment on a basis prohibited by local, state, or federal law. Equal access to employment, services,
and programs is available to all persons. Those applicants requiring reasonable accommodation to the
application and/or interview process should notify a representative of the organization.
Applicant name: _____________________________________________ Date:__________________
Position(s) applied for or type of work desired: ______________________________________________
Address: ____________________________________________________________________________
Telephone #: ________________________________ Social Security #:__________________________
Type of employment desired: _____ Full-time ____ Part-time
Date you will be available to start work: ____________________________________________________
Days and hours you are available: ________________________________________________________
Are you able to meet the attendance requirements? _____ Yes _____ No
Do you have any objection to working overtime if necessary? _____ Yes _____ No
Can you travel if required by this position? _____ Yes _____ No
Have you ever been previously employed by our organization? _____ Yes _____ No
Can you submit proof of legal employment authorization and identity? _____ Yes _____ No
If you are under 18, can you furnish a work permit if it is required? _____ Yes _____ No
Have you ever been convicted of a crime in the last seven years? _____ Yes _____ No
If yes, please explain (a conviction will not automatically bar employment):
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________________Driver's license number (if driving is an essential job
duty):_____________________________________
How were you referred to us? ____________________________________________________________
Employment History
Please provide all employment information for your past three employers starting with the most recent.
Employer: ________________________________________Position held: ________________________
Address: ___________________________________________ Telephone #: _____________________
Immediate supervisor and title: __________________________________________________________
Dates employed: From _________________To ______________ Salary/Wages: ___________________
Job description/Responsibilities:__________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Reason for leaving: ____________________________________________________________________
Employer: ________________________________________Position held: ________________________
Address: ___________________________________________ Telephone #: _____________________
Immediate supervisor and title: __________________________________________________________
Dates employed: From _________________To ______________ Salary/Wages: ___________________
Job description/Responsibilities:__________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Reason for leaving: ____________________________________________________________________
Employer: ________________________________________Position held: ________________________
Address: ___________________________________________ Telephone #: _____________________
Immediate supervisor and title: __________________________________________________________
Dates employed: From _________________To ______________ Salary/Wages: ___________________
Job description/Responsibilities:__________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Reason for leaving: ____________________________________________________________________
Other Skills and Qualifications
Summarize any job-related training, skills, licenses, certificates, and/or other qualifications:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Educational History
List school name and location, years completed, course of study, and any degrees earned:
High school: _________________________________________________________________________
College:_____________________________________________________________________________
Technical training:_____________________________________________________________________
Other: ______________________________________________________________________________
References
List 3 references names, telephone numbers, and years known (do not include relatives or employers):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this
application from all previous employers, educational institutions, and references. I also hereby release from liability the
potential employer and its representatives for seeking, gathering, and using such information to make employment
decisions and all other persons or organizations for providing such information.
I understand that any misrepresentation or material omission made by me on this application will be sufficient cause
for cancellation of this application or immediate termination of employment if I am employed, whenever it may be
discovered.
If I am employed, I acknowledge that there is no specified length of employment and that this application does not
constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the
relationship at will, with or without cause, at anytime, so long as there is no violation of applicable federal or state law.
I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified
individual with a disability because of that persons need for a reasonable accommodation as required by the ADA.
I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work
authorization within three days of being hired. Failure to submit such proof within the required time shall result in
immediate termination of employment.
I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these
conditions.
Applicant Signature: __________________________ Date:______________________________