Employment Application

Applicant Information

Last Name*
First Name*

Middle Initial*
Social Security Number*

Street Address

City
State
Zip Code

Phone Number*
Email*

If hired, can you provide evidence of legal eligibility to work in the U.S.?

Yes No

Any offer of employment is conditioned upon completing form I-9 and providing the appropriate documents for identity and work authorization.

Date of Birth
Wage/Salary Desired

Full Time Part Time

Date you can begin work?

Are you over the age of 18?

Yes No

If under 18 years of age, you will be required to submit a birth certificate or work certificate as required by state or federal law.

Name of high school attended
City & State

Graduate?

Yes No

GED?

Yes No

Name of college or technical school
City & State

Graduate?

Yes No

Degree
Major

Are you presently enrolled in school?

Yes No

If yes, give name & address of school and expected degree date

List any job-related skills or accomplishments, including military service

Have you ever been convicted of a felony?

Yes No

Do you consent to a pre-employment drug test?

Yes No

Your Availability For Work

Mon.

Tue.

Wed.

Thu.

Fri.

Sat.

Sun.

From

Total hours per week you are available to work:

Do you have reliable transportation?

Yes No

Three References

Provide Three References Who Are Not Family Members, Who We May Contact

Name and Occupation (1)

How do you know them, and for how long?
Phone Number

Name and Occupation (2)

How do you know them, and for how long?
Phone Number

Name and Occupation (3)

How do you know them, and for how long?
Phone Number

Your Employment History

List names of employers with present or last employer listed first.

May we contact current employers before you are offered a position?

Yes No

Name of Employer (1)

Duties

Job Title

Address

City
State
Zip

Dates of Employment (From - To)

Hourly pay or salary:

Starting pay
Ending pay

Supervisor
Reason for Leaving

Name of Employer (2)

Duties

Job Title

Address

City
State
Zip

Dates of Employment (From - To)

Hourly pay or salary:

Starting pay
Ending pay

Supervisor
Reason for Leaving

Name of Employer (3)

Duties

Job Title

Address

City
State
Zip

Dates of Employment (From - To)

Hourly pay or salary:

Starting pay
Ending pay

Supervisor
Reason for Leaving

CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM

I certify that all of the information provided in this employment application is true and complete to the best of my knowledge, and J authorize investigation of all statements contained in this application, including a criminal background, credit history check, and drug test, as applicable, I understand that any false or incomplete information may disqualify me from further consideration for employment and may result in my immediate discharge if discovered at a later date.

I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer, past employers, and other organizations to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision. 1 release such persons and organizations from any legal liability in making such statements.

I have read, understand, and agree to the above statements.

Signature*

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