Sample Employment Application Form

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE APPLICATION FOR EMPLOYMENT APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS

PLEASE COMPLETE PAGES 1-5.

DATE _________________________________

Name ______________________________________________________________________________________________
Last First Middle Maiden

Present address _____________________________________________________________________________________

How long ____________________ Telephone ( )

Social Security No. _______ _____ _________

If under 18, please list age ____________________ Position applied for (1) _______________________ and salary desired (2) _______________________ (Be specific) How many hours can you work weekly? ________________________ Employment desired FULL-TIME ONLY Days/hours available to work No Pref _______ Thur _________ Mon _________ Fri __________ Tue __________ Sat __________ Wed _________ Sun _________ Can you work nights? _______________________ FULL- OR PART-TIME

PART-TIME ONLY

When available for work? _______________ ___________________________________________________________________________________________________

TYPE OF SCHOOL

NAME OF SCHOOL

LOCATION (Complete mailing address)

NUMBER OF YEARS COMPLETED

MAJOR & DEGREE

High School College Bus. or Trade School Professional School

HAVE YOU EVER BEEN CONVICTED OF A CRIME?

No

Yes

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. _________________________________________________ ___________________________________________________________________________________________________

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE APPLICATION FOR EMPLOYMENT

DO YOU HAVE A DRIVERS LICENSE?

Yes

No

What is your means of transportation to work? ______________________________________________________________ Drivers license number ____________________________ State of issue _______ Expiration date ______________________ Have you had any accidents during the past three years? Have you had any moving violations during the past three years? OFFICE ONLY Yes No Yes No Yes 10-key No Word Processing Yes No Operator Commercial (CDL) Chauffeur

How many? __________________ How Many? __________________

Typing Personal Computer

_____ WPM PC Mac

_____ WPM

Other ____________________________________________ Skills ____________________________________________

Please list two references other than relatives or previous employers. Name ________________________________________ Position ______________________________________ Company _____________________________________ Address ______________________________________ ______________________________________ Telephone ( ) Name ____________________________________________ Position __________________________________________ Company _________________________________________ Address __________________________________________ __________________________________________ Telephone ( )

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE APPLICATION FOR EMPLOYMENT MILITARY HAVE YOU EVER BEEN IN THE ARMED FORCES? ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? Yes No Yes No

Specialty __________________________________ Date Entered ________________ Discharge Date ______________ Work Experience Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary. Name of last supervisor Employment dates From To Your last job title Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company. Pay or salary Start Final

Name of employer Address City, State, Zip Code Phone number

Name of employer Address City, State, Zip Code Phone number

Name of last supervisor

Employment dates From To

Pay or salary Start Final

Your Last Job Title Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE APPLICATION FOR EMPLOYMENT Work experience Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary. Name of last supervisor Employment dates From To Your last job title Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company. Pay or salary Start Final

Name of employer Address City, State, Zip Code Phone number

Name of employer Address City, State, Zip Code Phone number

Name of last supervisor

Employment dates From To

Pay or salary Start Final

Your last job title Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

May we contact your present employer? Did you complete this application yourself

Yes Yes

No No

If not, who did? ______________________________________________________________________________________

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by ___________________ (hereinafter called the Company), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of , or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President /General Manager of the Company. Both the undersigned and 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 authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract. I also understand that (1) the Company has a drug and alcohol policy that provides for preemployment 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__________________________________________ Date: ___________________

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE POST EMPLOYMENT INFORMATION FORM TO BE COMPLETED AFTER EMPLOYEE HAS BEEN HIRED Height ______ ft. ______ in. Married Yes No Weight __________ Single Birth date _______________ Separated Divorced Widowed

If married, how long? _____

Full name of spouse ________________________________ Occupation ______________________________________ Name of company __________________________________ Telephone ( )

PERSON TO BE NOTIFIED IN CASE OF EMERGENCY Name ___________________________________________ Telephone ( )

Address __________________________________________ Relationship _____________________________________ FOR INSURANCE PURPOSES ONLY: LIST ALL DEPENDENTS

NAME

RELATIONSHIP

BIRTH DATE

SSN

TO BE COMPLETED BY EMPLOYER

Date of employment __________________ Job title ____________________ Dept. _____________________________ Location ____________________________ Rate of pay _________________ Full-time Part-time Salaried

Applicants signature acknowledging above inf ormation _______________________________________________________ Drug test confirmation number _______________________________ Name of person verifying information _____________________________________________________________________ Name of person authorizing employment __________________________________________________________________

Applicant Selection Criteria Record

CANDIDATES CONSIDERED (INCLUDING MINORITIES AND FEMALES) NAME MALE/ FEMALE ETHNIC CODE* ON LAB SECTION/ OFF LAB

*ETHNIC CODES: 1-BLACK, 2-ORIENTAL, 3-HISPANIC, 4-AMERICAN INDIAN, 0-OTHER CANDIDATE SELECTED NAME MALE/ FEMALE ETHNIC CODE SOURCE

SELECTION CRITERIA

REASONS CANDIDATE SELECTED WAS PREFERABLE TO OTHERS

ORIGINATOR'S SIGNATURE

DATE