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First Name

Last Name

Address

Address Line 2

City

Zip

** Paychecks will be sent to this address unless using direct deposit

Email address:

Cell Phone

Date Available

Desired Wage

Are you legally eligible for employment in this country?

Yes

Have you ever been employed here before?

Yes

If yes, give dates and Supervisor

Referral Source (How did you hear about us?)

Employment History

Latest Employer

Dates Employed FROM

Employer

Address

Address Line 2

City

Zip

Phone

Supervisor

Title

May we contact your supervisor

Yes

Later

Starting Wage

Hourly or Salary

Starting Job Title

Final Wage

Hourly or Salary

Final Job Title

Why did you leave?

Summarize the type of work performed and job responsibilities

What did you like most about your position?

What were the things you liked least about the position?

Previous Employer

Dates Employed FROM

Employer

Address

Address Line 2

City

Zip

Phone

Supervisor

Title

May we contact your supervisor

Yes

Later

Starting Wage

Hourly or Salary

Starting Job Title

Final Wage

Hourly or Salary

Final Job Title

Why did you leave?

Summarize the type of work performed and job responsibilities

What did you like most about your position?

What were the things you liked least about the position?

Skills & Qualifications

Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying

Education

Diploma

Degree

GED

Certification

Other

Additional Info:

Application Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for 90 days.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Name

Date

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