OR

Employment Application

Applicant Information

Applicant Name

Date:

Address/City/State/Zip:

Home Phone:

Cell Phone:

Social Security #:

Are you a United States Citizen?

Yes No

Date of Birth:

Gender:

Male Female

Marital Status:

Single Married Married, but withhold at higher single rate

Number of allowance you are claiming:

Driver’s License (State Id/#):

Alien Id #:

Nationality:

Emergency Contact:

Contact Name:

Relationship:

Phone

Contact Name:

Relationship:

Phone

1. Are you currently employed?

Yes No

2. Do you speak and understand English?

Yes No

If no, what language do you speak.

3. If hired, would you have transportation to /from work?

Yes No

4. What shift are you willing to work?

1st Shift 2nd Shift 3rd Shift

5. If applicable, are you available to work overtime?

Yes No

6. Are you legally eligible for employment in the United State?

Yes No

7. Are there any limitations, whether physical or otherwise, that may prevent you from performing a job?

Yes No

if yes, Please explain:

8. Are you willing to submit to and pass a controlled substance test?

Yes No

if no, Please explain:

Personal Data:

Have you been convicted of a crime (other than traffic violation) or been imprisoned during the last seven years? A conviction will not necessarily bar you from employment. (You are not required to disclose the existence of an arrest, criminal charge or conviction for which records have been erased).

Yes No

if yes, Please explain:

Education Record

High School College Trade

Years completed

Did you receive a degree or diploma?

Yes No

Name of school/address:

Applicant Employment History:

Employer Name 1:

Supervisor Name:

Address/city/state/zip:

Job Duties:

Reason for leaving:

Employer Name 2:

Supervisor Name:

Address/city/state/zip:

Job Duties:

Reason for leaving:

Employer Name 3:

Supervisor Name:

Address/city/state/zip:

Job Duties:

Reason for leaving:

Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention?

REFERENCES:

List two references that are familiar with the quality of your work, have known you at least two years, and are not related to you.

Reference 1

Phone

Address/city/state/zip:

Reference 2

Phone

Address/city/state/zip:

Please read carefully before signing:

Certification

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences immediate termination. I authorize to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational to fully and freely communicate information regarding my previous employment, and attendance. I authorize those persons designated to references to fully and freely communicate information regarding my previous employment.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

Applicant Digital Signature

Date

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