Applicant name:
Date
Address
Telephone #
Social Security #
Position (s) applied for or type of work desired:
Date you will be able to start work:
Referred by:
Drivers license # (if driving is an essential job duty):
If yes, please explain (a conviction will not automatically bar employment):
EMPLOYMENT HISTORY
Please provide all employment information for your past three employers starting with the most
recent.
Employer
Position Held
Address
Telephone #
Immediate supervisor and title:
Dates employed: From > To
Job summary
Reason for leaving:
Job 2
Employer
Position Held
Address
Telephone #
Immediate supervisor and title:
Dates employed: From > To
Job summary
Reason for leaving:
Job 3
Employer
Position Held
Address
Telephone #
Immediate supervisor and title:
Dates employed: From > To
Job summary
Reason for leaving:
How many jobs have you had in the last 10 years that are not listed above?
Why are you seeking a new position at this time?
OTHER SKILLS AND QUALIFICATIONS
Summarize any job-related training, skills, licenses, certificates and/or other qualifications?
EDUCATION HISTORY List school name and location, years completed, course of study, and any degrees earned.
High school:
College:
Technical training:
Other:
I hereby authorize the potential employer to contact, obtain and verify the accuracy of information
contained in this application from all previous employers and educational institutions. I also hereby
release from liability the potential employer and its representatives for seeking gathering and using
such information to make employment decisions and all other persons or organizations for
providing such information.
I understand that any misrepresentation or material omission made by me on this application will be
sufficient cause for cancellation of this application or immediate termination of employment if I am
employed, whenever it may be discovered.
If I am employed, I acknowledge that there is no specified length of employment and that this
application does not constitute an agreement or contract for employment. Accordingly, either the
employer or I can terminate the relationship at will, with or without cause, at any time, so long as
there is no violation of applicable federal or state law.
I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate
against a qualified individual with a disability because of that persons need for a reasonable
accommodation as required by the ADA.
I also understand that if I am employed I will be required to provide satisfactory proof of identity
and legal work authorization within three days of being hired. Failure to submit such proof within
the required time shall result in immediate termination of employment.
I represent and warrant that I have read and fully understand the foregoing and that I seek
employment under these conditions.
Full Name
Date
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