Employment Application Date / Time * Name First Middle Last Adress Phone Number If under 18 Please list age Do you smoke? Yes No Do you have a VALID driver’s license? Yes No Driver's Licence # State of issue Expiration Date Do you have a reliable form of transportation? If so, please list Are you seeking Part time, Full Time, or Either? Position applied for: 1 2 Salary Desired Have you ever been convicted of a crime? Yes No If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation Is there any existing physical disability(s) that would prevent you from performing fully the duties of the job for which you are applying? Education Name of School, Location, # of Years Completed Major & Degree High School College Trade School Are you now a member of the National Guard? Yes No Have you ever been in the Armed Forces? Yes No Please list three professional references Reference #1 Name Phone Company Reference #2 Name Phone Company Reference #3 Name Phone Company Have you ever been fired from a job? Yes No For what reason? Work Expirience Have you worked at this location previously? Yes No If so, when Please list previous employment starting with most recent job held. Job #1 Name of Employer First Last Supervisor Name Employment Dates: From To Pay: Start Final Job Title Reason for leaving Job #2 Name of Employer First Last Supervisor Name Employment Dates: From To Pay: Start Final Job Title Reason for leaving Job #3 Name of Employer First Last Supervisor Name Employment Dates: From To Pay: Start Final Job Title Reason for leaving May we contact these employers? Yes No Please explain the skill(s) you have gained, experience, and/or promotions you received while at these/ this job(s). Both the undersigned and the employer may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job- related physical examinations. I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act. I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party. Signature of applicant Initials or name Date / Time
