Employment Application
First name:* Last Name:* Date:
05/27/2017
Position(s) applied for or type of work desired:*
Mailing Address:*
City:* State:* Zip:*
Telephone #:* E-mail Address:
Type of employment desired:* full-time part-time temporary
Date you will be available to start work: *
How were you referred to us?
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  
Are you over 18 years of age?* Yes No  
Have you been convicted of a crime in the last 7 years?* Yes No  
If yes, please explain (a conviction will not automatically bar employment):

Employment History

Please provide all employment information for your past four employers starting with the most recent.

Previous Employer 1

Employer:* Position held: *
Address:* Telephone #:*
City:* State:* Zip:*
Immediate supervisor:* Supervisor's title:*
Dates employed: from* to* Salary:*
Job summary: *
Reason for leaving: *

Previous Employer 2

Employer:* Position held: *
Address:* Telephone #:*
City:* State:* Zip:*
Immediate supervisor:* Supervisor's title:*
Dates employed: from* to* Salary:*
Job summary: *
Reason for leaving: *

Previous Employer 3

Employer:* Position held: *
Address:* Telephone #:*
City:* State:* Zip:*
Immediate supervisor:* Supervisor's title:*
Dates employed: from* to* Salary:*
Job summary: *
Reason for leaving: *

Previous Employer 4

Employer:* Position held: *
Address:* Telephone #:*
City:* State:* Zip:*
Immediate supervisor:* Supervisor's title:*
Dates employed: from* to* Salary:*
Job summary: *
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:
Reference 1: Reference 2: Reference 3:

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 any time, 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 person's need for a reasonable accommodation as required by the ADA.

I 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 also understand that a condition of employment is passing a pre-employment drug screening and background check. I agree to these conditions.

Application Date: 05/27/2017
   I agree with the terms and conditions above.*
   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 any time, 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 person's need for a reasonable accommodation as required by the ADA. If I need an accommodation, I will notify the employer before I accept an offer, or as soon as possible after the need arises.*
   I 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 understand that a condition of employment may be passing a pre-employment drug screen and background check. A positive drug screen will disqualify me from positions where safety is a concern, or where driving is required, a poor driving record will disqualify me from positions where driving is required, and criminal convictions may disqualify me from positions where I may be granted access to security-sensitive work sites or information.*
   I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.*
   By checking this box, I hereby sign this application.*
   Please send me a copy of the completed application.
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