Your Contact Information

Full Name (required)

Your Email (required):

Telephone:

Best time to call you:
 Morning Noon Afternoon Evening

Address:

City:

State:

Zip Code:

Information for Employment

Birth Date (If under 18):

Date available for work:

Desired hours per week:

Have you ever pleaded “guilty” or “no contest" to a crime? Or have you ever been convicted of a crime?:
Note: Answering “yes” to the above question does not constitute an automatic bar to employment, factors such as date of the offense, seriousness and nature of the violation and rehabilitation will be taken into account.
 Yes No

Type of employment desired:
 Full Time Part time Temporary Seasonal

Specify below hours and days available:
(example: Monday:8-5)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Are there any commitments, activities, vacation plans, etc., that could effect your availability for work?
 Yes No
Explain:

Employment History

Employer #1

Please provide the following information of your past and current employers, assignments or volunteer activities starting with the most recent.

Employer:

Telephone:

Address:

Dates Employed:

Job Title:

Supervisor:

Reason for leaving:

May we contact for reference:

If no, please explain:

Employer #2

Please provide the following information of your past and current employers, assignments or volunteer activities starting with the most recent.

Employer:

Telephone:

Address:

Dates Employed:

Job Title:

Supervisor:

Reason for leaving:

May we contact for reference:

If no, please explain:

Employer #3

Please provide the following information of your past and current employers, assignments or volunteer activities starting with the most recent.

Employer:

Telephone:

Address:

Dates Employed:

Job Title:

Supervisor:

Reason for leaving:

May we contact for reference:

If no, please explain:

Employment history additional information
Enter below any additional information concerning employment history:

Educational Background

Please list the following: The last three schools attended, starting with the most recent and the number of years completed. Indicate degree or diploma earned, if any. Grade point average or class rank. Major field of study and minor field of study, if applicable.

School #1

School attended:

Years completed:

Degree/Diploma:

G.P.A./Class Rank:

Major/Minor:

School #2

School attended:

Years completed:

Degree/Diploma:

G.P.A./Class Rank:

Major/Minor:

School #3

School attended:

Years completed:

Degree/Diploma:

G.P.A./Class Rank:

Major/Minor:

References

Please list name and telephone number of three business/work, or school/personal references who are not related to you and are not previous supervisors.

Reference #1

Reference Name:

Telephone:

Occupation:

How long have you known this person:

Reference #2

Reference Name:

Telephone:

Occupation:

How long have you known this person:

Reference #3

Reference Name:

Telephone:

Occupation:

How long have you known this person:

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct to the best of my knowledge, and that I have withheld no information or other response that would, if disclosed, affect this application unfavorably. I expressly authorize, without reservation, the employer to contact and obtain information from all references (personal and professional), to otherwise verify the accuracy of all information provided by me in this application. I understand that any misleading or incorrect statements or responses may render this application void and, if employed, may result in my immediate termination regardless of when the misleading or incorrect statement or response was discovered. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I understand that this application does not constitute an agreement or contract for employment for any specified period or definite duration. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice and that the employer reserves the same right to terminate my employment at any time, without any cause or prior notice, except as may be required by law.

I certify that I have read, fully understand and accept all terms of the foregoing applicant statement.
 Yes No