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Employment Application

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Position(s) applied for Your Name
Last

Middle

First
Address
E-mail Address Cellular/Other #
Referral Source
(How did you hear about us?)		 Telephone #
If you are under 18 and it is required, can you furnish a work permit? Yes No If no, please explain:
Have you ever been employed here before? Yes No If yes, give dates and positions:
Is this application a request for reemployment following an extended military leave of absence from this company? Yes No  
Are you legally eligible for employment in this country? Yes No Date available for work
What is your desired salary range? Type of employment desired
Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)?

This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.		 Yes
No
Need more information about the job's "essential functions" to respond
Driver's license number required if driving may be required in the job for which you are applying:
State of Driver's license
EMPLOYMENT HISTORY
Employer 1 Telephone
Address
(Street, City, State, Zip)		 Starting job title/Final job title
Immediate supervisor and title (for most recent position held)
 Supervisor E-mail

 May we contact for reference? Yes No Later
Why did you leave? Summarize the type of work performed and job responsibilities
Dates employed Compensation
 
Employer 2 Telephone
Address
(Street, City, State, Zip)		 Starting job title/Final job title
Immediate supervisor and title (for most recent position held)
 Supervisor E-mail

 May we contact for reference? Yes No Later
Why did you leave? Summarize the type of work performed and job responsibilities
Dates employed Compensation
Summarize any special training, skills, licenses and/or certifications that may assist you in performing the position for which you are applying
COMPUTER SKILLS
(Check appropriate boxes. Include software titles and years of experience.)
 Word Processing Years:  Spreadsheet Years:
 Presentation Years:  E-mail Years:
 Internet Years:  Other Years:
EDUCATIONAL BACKGROUND
Starting with your most recent school attended, provide the following information.
School
(include City & State)
 Years Completed  GPA Class Rank Completed Major/Minor
School
(include City & State)
 Years Completed  GPA Class Rank Completed Major/Minor
School
(include City & State)
 Years Completed  GPA Class Rank Completed Major/Minor
REFERENCES
List names and telephone numbers of three business/work references who are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
Name Title Relationship
Telephone E-mail Years Known
Name Title Relationship
Telephone E-mail Years Known
Name Title Relationship
Telephone E-mail Years Known
SOCIAL SECURITY NUMBER
SS# We will use this information only for employment purposes and make reasonable efforts to safeguard your privacy.

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resumé or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for finishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of l imiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specific period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that f ederal immigration laws require me to complete an I-9 Form in this regard. This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status. The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SUBMIT UNTIL YOU HAVE READ THE ABOVE APLICANT STATEMENT.

 I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.