"*" indicates required fields NameThis field is for validation purposes and should be left unchanged.We appreciate your interest in our organization. To be considered for employment, this Employment Application must be completed and signed personally by the applicant. Applicants requiring a reasonable accommodation to participate in the application and/or interviewing process should notify an organization representative. Each question must be answered in full, even if a resume is provided. If an answer is NO or NOT APPLICABLE, indicate such. We are an Equal Opportunity Employer. We consider all applicants for all positions without regard to race, religion, creed, color, sex, age, national origin, disability, sexual orientation, gender identity or expression, transgender status, gender dysphoria, marital or family status, pregnancy, military/veteran status, genetic information including predisposing genetic characteristics or carrier status, arrest or conviction record, domestic violence victim status, or any other protected class or status, in accordance with applicable federal, state, and local regulations.BIOGRAPHICAL DATAPrint Name (First, Middle, Last)Telephone NumberCell Phone NumberStreet AddressCityStateZip CodeE-mail Address* Position Applied ForPlease indicate the days you are available to work: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Select AllAre you Available to Work (check all that apply) Full-Time Part-Time Temporary Shift Work Day Evening Nights Select AllDate Available to Begin Work MM slash DD slash YYYY Are you 18 years of age or older? Yes No Are you currently employed? Yes No if yes, may we contact your employer to obtain employment information? Yes No Have you ever submitted an application and/or interviewed for employment with our organization? Yes No give dates and position:Have you ever been employed with our organization before? Yes No If yes, give dates.From MM slash DD slash YYYY To MM slash DD slash YYYY Are you legally eligible for employment in the United States? Yes No Employment eligibility will be verified upon employment.If you have had an opportunity to review a job description for the position for which you are applying, can you perform the essential functions of this job with or without reasonable accommodation? (check N/A if you have not reviewed a job description) Yes No N/A EDUCATIONAL BACKGROUNDHigh SchoolName and Location of SchoolCourse of Study/MajorYears CompletedDiploma or Degree Earned Diploma GED College/UniversityName and Location of SchoolCourse of Study/MajorYears CompletedDiploma or Degree Earned Associate Bachelor Graduate SchoolName and Location of SchoolCourse of Study/MajorYears CompletedDiploma or Degree Earned Master Doctoral Trade SchoolName and Location of SchoolCourse of Study/MajorYears CompletedDiploma or Degree Earned Certificate SKILLSList any additional skills, training, and/or technical/professional knowledge and/or certificates, licenses or achievements that is relevant to the job for which you are applying:Drivers’ License Identification Number:State of Issuance:(Provide your driver's license ID number ONLY if it is a requirement of the position for which you are applying)EMPLOYMENT HISTORYProvide employment information, including military service starting with the most recent employerfirst. If you've held more than three jobs, provide this information on another sheet and attach to this Application Form.Name of EmployerSupervisorMay we contact? Yes No AddressPhone NumberJob TitleDates Employed (Month/Year)From MM slash DD slash YYYY To MM slash DD slash YYYY Description of Duties, Responsibilities and Significant AccomplishmentsReason for LeavingName of EmployerSupervisorMay we contact? Yes No AddressPhone NumberJob TitleDates Employed (Month/Year)From MM slash DD slash YYYY To MM slash DD slash YYYY Description of Duties, Responsibilities and Significant AccomplishmentsReason for LeavingName of EmployerSupervisorMay we contact? Yes No AddressPhone NumberJob TitleDates Employed (Month/Year)From MM slash DD slash YYYY To MM slash DD slash YYYY Description of Duties, Responsibilities and Significant AccomplishmentsReason for LeavingREFERENCES (List three references other than relatives) NameRelationshipPhone Number or EmailNameRelationshipPhone Number or EmailNameRelationshipPhone Number or EmailCONVICTION RECORD STATUSAll applicants and employees must, as a condition of employment, inform the organization of all convictions. This includes all convictions received within the past seven years, while your application for employment is pending, and within seven days of receiving a conviction if currently employed.Have you been convicted of, and/or plead guilty to, a felony or misdemeanor in the past seven years? Yes No Do you have any currently pending arrests or accusations against you at this time? Yes No If you answered ‘yes’ and have been convicted of a felony or misdemeanor, please provide additional information below, such as the crime(s), date(s), court location, sentencing information, disposition of sentence, and rehabilitation completed. Only job-related convictions will be considered and will not automatically disqualify an applicant. Employment decisions based on a conviction take into consideration many factors, including but not limited to, age and date of conviction, the extent to which the offense relates to the functions of the particular job, the seriousness of the offense, rehabilitation, etc. The organization reserves the right to reject individuals for employment based on job-related convictions.Date of OffenseCounty and State in which Offense OccurredConviction/ExplanationRehabilitation CompletedDate of OffenseCounty and State in which Offense OccurredConviction/ExplanationRehabilitation CompletedPLEASE READ CAREFULLY AND SIGN BELOWI hereby certify that all of the information I have provided on this Employment Application is true and correct to the best of my knowledge. I understand that any misrepresentation or omission of facts will disqualify me from further consideration of employment, withdrawal of any offer of employment, or, termination of employment, if already hired. I authorize verification of all of the information I have provided on this Employment Application and understand that additional information may be needed to consider my application for employment. I authorize all previous employers, educational institutions, references, and other persons who have knowledge of me or my records to provide any and all information pertinent to my employment and release the same from any liability resulting from providing such information. I also release this organization and all of its employees from all liability for any damage that may result from reliance on the information furnished. After a conditional offer of employment, I understand that a pre-employment medical examination must be passed to the organizations satisfaction before starting work. The organization is committed to providing a drug and alcohol-free workplace. After receiving a conditional offer of employment, I understand that a drug test will be required before starting work. If the results of the test are positive, I understand that the offer of employment will be withdrawn. I understand that if employed, I am required to abide by all policies, procedures, rules, and regulations of the organization. I also understand and agree that, if hired, my employment is “at-will” and is for no definite period and may, regardless of the date of payment of my wages or salary, be terminated by myself or the organization at any time with or without cause or notice. Date MM slash DD slash YYYY Signature of ApplicantMax. file size: 2 GB. Δ
