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Employment Application

"*" indicates required fields

Applicant Information

Full Name:*

First Middle Initial Last

Address:*

Street Address City State ZIP Code

Phone/Cell:*

Email:*

Date available:*

Month

Day

Year

Desired salary:*

Position applying for:*

Have you ever applied to this company?*

Yes

If yes, when?

Days available to work:*

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Shift or hours you can work:*

Days

Evenings

Nights

Can you work overtime if requested?*

Yes

Are you under the age of 18?*

Yes

Previous Employment #1

Company:*

Phone:*

Address:*

Supervisor:*

First Last

Job Title:*

Starting Salary:*

Ending Salary:*

Responsibilities*

From:*

Month

Day

Year

To:*

Month

Day

Year

Reason for leaving:*

May we contact your previous supervisor for a reference?*

Yes

Previous Employment #2

Company:

Phone:

Address:

Supervisor:

First Last

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

From:

MM slash DD slash YYYY

To:

MM slash DD slash YYYY

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes

Disclaimer and Signature

In order for us to be able to process your application, please review and check the box next to each of the statements below:

True Statements*

I declare that all statements contained in this application are true and that any misrepresentation or omission may result in rejection of my application and/or termination of my employment at any time.*

Background Check*

I authorize you to conduct a criminal background check, as well as personal and professional background checks, for the purposes of consideration of this application. You may contact any references, past and current employers, and any other individual or organization that might be relevant to the position for which I am applying—except for those specifically excluded in writing on this application. I hereby release all of these references, employers and other individuals/organizations from any and all liability for damages that might occur in connection with the processing of this application.*

At Will*

If extended an offer of employment, I understand and agree that my employment relationship with this organization is an “at-will” relationship, meaning that both the organization and I have the right to terminate this employment relationship at any time for no reason or for any reason, as long as that reason is not illegal. No verbal promises or guarantees can change this at-will relationship. Any changes to the at-will relationship or its terms must be in writing, for the agreed purpose of changing the relationship, and signed by me and by an authorized officer of this organization. (For further information, please consult this organization’s at-will policy.)*

EEO Policy*

This organization prohibits and does not tolerate discrimination in any form, including harassment, on the basis of race, color, national origin, religion, sex, age, veteran, familial or marital status, disability, genetics, sexual orientation, or any other protected category of individuals. This organization is an equal opportunity employer and makes hiring and other employment decisions based on job-related qualifications, abilities, and factors other than on the basis of the race, color, national origin, religion, sex, age, veteran, familial or marital status, disability, genetics, sexual orientation, or any other protected category of individuals. (For further information, please consult this organization’s EEO policy.)*

Signature*

My signature indicates that I have read all of the above statements, that I asked any questions I may have had, and that I fully understand all of these statements.*

Signature*

Typing in your name here indicates a signature.

Date:*

MM slash DD slash YYYY