EMPLOYEE APPLICATION 

POSITION (S) DESIRED

APPLICATION DATE

LAST NAME

FIRST NAME                                                  MIDDLE INITIAL

ADDRESS

CITY                                                     STATE                           ZIP

HOME TELEPHONE                                  ALTERNATE PHONE

SOCIAL SECURITY #

DATE AVAILABLE TO START:   

DAY/HOURS AVAILABLE:

DRIVER’S LICENSE #

EMPLOYMENT TYPE:

 Full-Time   Part-Time   Temporary   Seasonal  
 Other: _______________

 DESIRED SALARY: ­­__________________

Where you previously employed by this organization?

 Yes, Date(s) __________________ No

If under 18, please list age: ______

 List any relatives or friends working for this organization:

 Name: _________________________________________    Relationship: ______________________________________

 Name: _________________________________________    Relationship: ______________________________________

WORK EXPERIENCE 

 
Company Name and Address: _______________________________________________ 

Telephone: ________________________________________________

 Position Held: ________________________________________________

 Supervisor and Title:


 _______________________________________________

Month/Year:  __________________________________________________

Salary: ____________________________________________

 Duties & Responsibilities:

__________________________________________________

  Reason for leaving:

 __________________________________________________

 
Company Name and Address: _______________________________________________ 

Telephone: ________________________________________________

 Position Held: ________________________________________________

 Supervisor and Title:


 _______________________________________________

Month/Year:  __________________________________________________

Salary: ____________________________________________

 Duties & Responsibilities:

__________________________________________________

  Reason for leaving:

 __________________________________________________

 
Company Name and Address: _______________________________________________ 

Telephone: ________________________________________________

 Position Held: ________________________________________________

 Supervisor and Title:


 _______________________________________________

Month/Year:  __________________________________________________

Salary: ____________________________________________

 Duties & Responsibilities:

__________________________________________________

  Reason for leaving:

 __________________________________________________

May we contact the above employers?     Yes    No

Type of School

Name of School

Location

Years Completed

Major & Degree

High School

College

Business/Trade School

Professional School

HAVE YOU EVER BEEN CONVICTED OF A CRIME?     Yes     No

If yes, explain number of  conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation:

ARE YOU ELIGIBLE TO WORK IN THE UNITED STATES?  Yes   No

ARMED FORCES

Have you ever been in the armed forces?                        Yes    No

Are you now a member of the national guard?               Yes   No

Specialty                                                                         Date Entered                                                      Discharge Date

Please list four references other than relatives or previous employers:

Name:

Name:

Position:

Position:

Company:

Company:

Address:

Address:

Telephone Number:

Telephone Number:

Name:

Name:

Position:

Position:

Company:

Company:

Address:

Address:

Telephone Number:

Telephone Number:

Typing:  (  ) Yes    WPM ______   (  ) No                   10-Key:  Yes   No                   Word Processing:  Yes   No                                                 

Other Skills:_________________________________________________________________________________________________

What is your most important career goal?

Where do you see yourself in five years?

List three things you like most about your current company/job.

List three things you like least about your current company/job.

Are you willing to travel? 

Agreement of the Transfer of Information

I declare the information provided by me in this application is true, correct, and complete to the best of my knowledge. I understand that if employed, any falsification, misstatement, or omission of fact in connection with my application, whether on this document or not, may result in immediate termination of employment. I authorize you to verify any and all information provided above.  I acknowledge that employment may be conditional upon successful completion of a substance abuse screening test as part of the Company's pre-employment policy.  I acknowledge that if I become employed, I will be free to terminate my employment at any time for any reason, and that (Company Name) retains the same rights. No (Company Name) representative has the authority to make any contrary agreement.  I understand it is unlawful to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal and/or civil liabilities.

Signature: ________________________________________Date:__________

Printed Name: _________________________________________