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Employment Application
Programs, services and employment are available to everyone equally. Please inform the Human Resources Department of you require reasonable accommodation for the application or interview.
APPLICANT DATA:
Position applied for:
Name: First Init. Last
Address: City: State: Zip:
Phone: Cell: E-mail Address:
Date avail. to start: Social Security #: Salary Requirement:
If you are under 18 and we require a work permit, can you furnish one?: Yes No
Have you ever worked for this company?: Yes No      If yes, when?
Are you a U.S. citizen?: Yes No      If not, are you allowed to work in the U.S.? Yes No
Type of employment desired?: Full-time Part-time Temporary Seasonal
Have you ever pled "guilty", "no contest", or been convicted of a crime?: Yes No
If yes, give dates and details:
Answering "yes" to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be considered.
Driver's license number if applicable to position: State:
Who referred us to you?:
EDUCATION:
High School: Address:
# of Years Completed:      Did you graduate? Yes No      Degree:
GPA: Class Rank:
College/University: Address:
# of Years Completed:      Did you graduate? Yes No      Degree:
GPA: Class Rank:
Other: Address:
# of Years Completed:      Did you graduate? Yes No      Degree:
GPA: Class Rank:
REFERENCES:
Name: Phone:
Address: City: State: Zip:
Name: Phone:
Address: City: State: Zip:
SUMMARIZE YOUR SPECIAL SKILLS OR QUALIFICATIONS:
PREVIOUS EMPLOYMENT (begin with most recent position):
Dates of Employment:      From To      Position(s) Held:
Firm: Address:
Phone: Supervisor: Title:
Responsibilities:
Starting Salary and Title: Ending Salary and Title:
Reason for Leaving:
May we contact this employer for a reference?: Yes No
Dates of Employment:      From To      Position(s) Held:
Firm: Address:
Phone: Supervisor: Title:
Responsibilities:
Starting Salary and Title: Ending Salary and Title:
Reason for Leaving:
May we contact this employer for a reference?: Yes No
Dates of Employment:      From To      Position(s) Held:
Firm: Address:
Phone: Supervisor: Title:
Responsibilities:
Starting Salary and Title: Ending Salary and Title:
Reason for Leaving:
May we contact this employer for a reference?: Yes No
 
I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial, or medical history and other related matters as may be necessary for an employment decision. I hereby release employers, schools or persons from all liability when responding to inquiries in connection with my application.

In the event I am employed, I understand that false or misleading inforamtion given in my application or interview(s) may result in discharge.
Check box to certify
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