Employment

EMPLOYMENT APPLICATION

DATE

NAME

ADDRESS

CITY,STATE, ZIP CODE

PHONE #

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EMPLOYMENT POSITION

POSITION APPLYING FOR

HOW DID YOU HEAR ABOUT THIS POSITION?

WHEN CAN YOU START?

DO YOU HAVE RELIABLE TRANSPORTATION TO AND FROM WORK?

SALARY DESIRED:

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PERSONAL INFORMATION

ARE YOU 18 YEARS OR OLDER?

DRIVER’S LICENSE #

ARE YOU A U.S. CITIZEN OR APPROVED TO WORK IN THE UNITED STATES?

WHAT DOCUMENTATION CAN YOU PROVIDE AS PROOF OF CITIZENSHIP OR LEGAL STATUS?

WILL YOU CONSENT TO A MANDATORY CONTROLLED SUBSTANCE TEST?

HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENSE? (FELONY OR MISDEMEANOR)

IF YES, PLEAS STATE THE NATURE OF THE CRIME(S), WHEN AND WHERE CONVICTED AND DISPOSITION OF THE CASE:

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(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense, the date of the offense, nature of the

offense, including any significant details the affect the description of the event, and the surrounding circumstances and the relevance of the

offense to the position(s) applied for many, however, be considered.

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JOB SKILL/QUALIFICATIONS

PLEASE LIST BELOW THE SKILLS AND QUALIFICATIONS YOU MAY HAVE FOR THE POSITION FOR WHICH YOU ARE APPLYING

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EDUCATION AND TRAINING

HIGH SCHOOL

LOCATION

YEAR COMPLETED

DEGREE EARNED

COLLEGE/ UNIVERSITY

LOCATION

YEAR COMPLETED

DEGREE EARNED

VOCATIONAL/ SPEC TRAINING

LOCATION

YEAR COMPLETED

DEGREE EARNED

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MILITARY

ARE YOU A MEMBER OF THE ARMED SERVICE?

BRANCH

RANK AND DISCHARGE

YEARS OF SERVICE

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PREVOUS EMPLOYMENT

EMPLOYER NAME:

JOB TITLE

SUPERVISOR NAME

EMPLOYER PHONE #

DATE OF EMPLOYMENT

REASON FOR LEAVING

RATE OF PAY

EMPLOYER NAME

JOB TITLE

SUPERVISOR NAME

EMPLOYER PHONE #

DATE OF EMPLOYMENT

REASON FOR LEAVING

RATE OF PAY

EMPLOYER NAME

JOB TITLE

SUPERVISOR NAME

EMPLOYER PHONE #

DATE OF EMPLOYMENT

REASON FOR LEAVING

RATE OF PAY

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REFERENCES

PLEASE PROVIDE 3 NO RELATED REFERENCES BELOW:

NAME

OCCUPATION

PHONE NUMBER

YEARS KNOWN

NAME

OCCUPATION

PHONE NUMBER

YEARS KNOWN

NAME

OCCUPATION

PHONE NUMBER

YEARS KNOWN

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AUTHORIZATION

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my pervious employment and any pertinent information they may have, personal or otherwise, and release the company form all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

SIGNATURE

DATE

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EMPLOYMENT APPLICATION