Employment Application

Applications are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or in the presence of a non-related medical condition or handicap.

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Cell or Alternate #

Email(Required)

Social Security #(Required)

Over the Age of 18?(Required)

Yes

Are you a citizen of the United States of America?(Required)

Yes

Have you applied here before?(Required)

Yes

Position applied for?(Required)

When?(Required)

MM slash DD slash YYYY

Start When(Required)

Job Types(Required)

Full time

Part time

Temporary Position

Applying For?(Required)

Sales

Service

Office

Inside Sales

Installation

Warehouse

Describe any special qualifications for this job:(Required)

Recruitment Source: Please Check box(es) that prompted you to apply.(Required)

Walk-In

Was Recruited

Special Program

Agency Referral

Employee Referral

School

Advertising

Other

Employee Referral Name(Required)

Advertising Name(Required)

Drivers License

License Number(Required)

License State(Required)

State

Expiration(Required)

MM slash DD slash YYYY

Are you a veteran of the U.S. Military service?(Required)

Yes

Have you ever been convicted of a Felony?(Required)

Yes

If yes, please specify:(Required)

Hidden

For Personnel Department only Remarks

EDUCATION

Colleges Attended:

Name #1

# Years

Year Grad.

Address

Street Address City State ZIP Code

Degree/Specialized area of study:

Name #2

# Years

Year Grad.

Address

Street Address City State ZIP Code

Degree/Specialized area of study:

High School Attended:

Name(Required)

Phone(Required)

Address(Required)

Street Address City State ZIP Code

Did you graduate?(Required)

Yes

Extracurriculars or Honors/Awards

Community Service

Employment

Employer 1

Employer Name

Phone #:

Address

Street Address City State ZIP Code

Supervisors’ Name

Job Title

Reason for leaving

Dates of Employment

From

MM slash DD slash YYYY

Salary or Hourly Rate

Employer 2

Employer Name

Phone #:

Address

Street Address City State ZIP Code

Supervisors’ Name

Job Title

Reason for leaving

Dates of Employment

From

MM slash DD slash YYYY

Salary or Hourly Rate

Employer 3

Employer Name

Phone #:

Address

Street Address City State ZIP Code

Supervisors’ Name

Job Title

Reason for leaving

Dates of Employment

From

MM slash DD slash YYYY

Salary or Hourly Rate

As a candidate, you agree to and understand the following:

1. All personally identifiable information will be held in confidence and properly safeguarded, and the use of such information will be limited to valid business or legal requirements.

2. This company has a policy prohibiting the use of illegal drugs. A drug urinalysis test is required prior to employment. By signing this application, you indicate your awareness that, in accordance with this policy, a positive test result may be sufficient to disqualify you for employment or, if employed, may result in your dismissal.

INITIAL(Required)

Date(Required)

MM slash DD slash YYYY

3. You must meet minimum age requirements of applicable laws.

4. This company may conduct investigations, including verification of prior employment history and education. By signing this application, you authorize this company, or its agents, to make these investigations and you indicate your awareness that false statements or failure to disclose information may be sufficient to disqualify you for employment or, if employed may result in your dismissal.

5. If a job offer is made, you will be required by the Immigration Reform and Control Act of 1986 to verify your identity and eligibility to work in the United States.

6. This company adheres to state and local regulations regarding clean air in the work place and reserves the right to restrict smoking in company-owned or leased buildings.

7. This company is an at-will employer. Neither this document, nor any other, is intended to be a contract of employment.

8. In addition to this application, there are certain other documents that the company will require you to sign as a condition of employment. Failure to sign may result in your dismissal.

Please provide your signature and the date below to indicate that you agree to and understand all the information contained in this application.

Furthermore, your signature indicates that you understand that this application will remain active for 12 months from the date below. Following that date, to assure consideration for a position, a new application must be completed.

Applicant’s Signature(Required)

Date(Required)

MM slash DD slash YYYY