Employment Application

 

 

                                                                                                                                                                  Date: _________________

Applicant’s Name _________________________________________

 

Address ________________________________________________________________________________________________

 

 

Daytime telephone __________________________ E-mail address _________________________________________________

 

Social Security Number ____________________________

 

Position for which you are applying ______________________________

 

How did you learn about this position? __________________________________________________________

 

Are you 18 years of age or older?   [    ] Yes   [    ] No

 

If you are hired for this position, can you provide written proof that you may legally work in the United States?

[    ] Yes   [    ] No

 

On what date are you able to commence work? ________________________

 

 

Employment History

 

Are you currently employed?   [   ] Yes   [   ] No

 

Starting with your current or most recent position, give the requested information:

 

1. Employer _________________________________________________________________

 

Address _______________________________________________________________________________________________________

 

Supervisor __________________________

 

Telephone number ___________________________ E-mail address ________________________________________________

 

Dates of employment ____________________ Salary ______________

 

Description of your job title and duties ________________________________________________________________________

 

________________________________________________________________________________________________________________

 

Reason for leaving position ___________________________________________________________________________________

 

May we contact this employer for a reference?   [    ] Yes   [     ] No

 

2. Employer _______________________________________

 

Address   ______________________________________________________________________________________________________

 

Supervisor ___________________________

 

Telephone number __________________________ E-mail address _________________________________________________

 

Dates of employment __________________     Salary _______________

 

Description of your job title and duties _______________________________________________________________________

 

 _______________________________________________________________________________________________________________

 

Reason for leaving position ___________________________________________________________________________________

 

May we contact this employer for a reference?   [    ] Yes    [    ] No

 

 

3. Employer _________________________________________________

 

Address   ______________________________________________________________________________________________________

 

Supervisor ______________________________________________

 

Telephone number __________________________ E-mail address _________________________________________________

 

Dates of employment __________________ Salary ______________

 

Description of your job title and duties _______________________________________________________________________

 

 _______________________________________________________________________________________________________________

 

 

Reason for leaving position ____________________________________________________________________________________

 

May we contact this employer for a reference?   [    ] Yes   [    ] No

 

 

List and explain any special skills relevant for the position for which you are applying that you have acquired from your employment

or other activities (include computer software in which you are proficient).

 

______________________________________________________________________________________________________________________________

 

______________________________________________________________________________________________________________________________

 

______________________________________________________________________________________________________________________________

 

______________________________________________________________________________________________________________________________

 

______________________________________________________________________________________________________________________________

 

______________________________________________________________________________________________________________________________

 

 

 

Educational History

 

 

Name and Address of School: ______________________________________________________________________________________

 

Study Specialty: _______________________________________________________________________________

 

Number of Years Completed: _____________________

 

Degree or Diploma: _______________________________

 

High School: ______________________________________

 

College: ___________________________________________

 

Graduate School: ___________________________

 

Other Education: ________________________________________________________________________

 

___________________________________________________________________________________________

 

____________________________________________________________________________________________

 

 

Describe any internships, other specialized training (including job-related experience in the United States military), extracurricular activities, licenses, or degrees that would be particularly helpful in performing this position.

 

________________________________________________________________________________________________________

 

________________________________________________________________________________________________________

 

________________________________________________________________________________________________________

 

________________________________________________________________________________________________________

 

________________________________________________________________________________________________________

 

________________________________________________________________________________________________________

 

________________________________________________________________________________________________________

 

To make inquiries about your work record, do we need any information about your name or your use of another?

[    ] Yes [    ] No  If you answer yes, please explain­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­___________________________________________

_______________________________________________________________________________________________________

 

References

 

1. Name ___________________________________________        Telephone _________________________

 

Address _______________________________________________ E-mail address _____________________________________

 

How long and in what context have you known this reference? _____________________________________________________

 

2. Name ___________________________________________        Telephone _________________________

 

Address _______________________________________________ E-mail address _____________________________________

 

How long and in what context have you known this reference? _____________________________________________________

 

 

3. Name ____________________________________________        Telephone ________________________

 

Address ________________________________________________ E-mail address ____________________________________

 

How long and in what context have you known this reference? _____________________________________________________

 

 

Applicant’s Declaration

 

I understand that the information given in this employment application will be used in determining whether or not I will be hired for this position. I have made certain to give only true answers and understand that any falsification or willful omission will be grounds for refusal of employment or dismissal.

 

I understand that the employer hires on an employment-at-will basis, which employment may be terminated either by me or the employer at any time, with or without cause, for any reason consistent with applicable state and federal law. If I am offered the position for which I am applying, it will be employment-at-will, unless a written instrument signed by an authorized executive of the employer changes this.

 

I know that this application is not a contract of employment. I am lawfully authorized to work in the United States and, if offered the position, will give whatever documentary proof of this as the employer may request.

 

I further understand that the employer may investigate and verify all information I have given in this application, on related documents (including, but not limited to, my résumé), and in interviews. I authorize all individuals, educational institutions, and companies named in this application to provide any information the employer may request about me, and I release them from any liability for damages for providing such information.

 

 

 

 

Applicant’s signature: __________________________________

                            

Date: __________________