General Employment Application Step 1 of 5 20% Personal InformationPosition Applied ForStarting Compensation ExpectedDate Available to Start MM slash DD slash YYYY Date of Application MM slash DD slash YYYY TelephoneAlternate TelephoneYour Name First Middle Last Date of Birth MM slash DD slash YYYY Your Email Address Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code AvailabilityFull Time YES NO Part Time YES NO How did you hear about our company and this job opening?Employment Agency (Name):Newspaper (Name):Employee Referral (Name):Previously Employed (Date):School (Name):Other:NOTE: We may refuse to hire relatives of present employees if doing so could result in actual or potential problems in supervision, security, safety, or morale, or if doing so could create conflicts of interest.NOTE: The Company complies with the Americans with Disabilities Act and the California Fair Employment and Housing Act and hires employees who are able to perform the essential functions of their jobs, with or without reasonable accommodations, without regard to any physical or mental disability. EducationHigh SchoolNameAddressNumber of Years CompletedDid You GraduateArea of Study and Degree(s) Received Add RemoveCollege/UniversityNameAddressNumber of Years CompletedDid You GraduateArea of Study and Degree(s) Received Add RemoveGraduateNameAddressNumber of Years CompletedDid You GraduateArea of Study and Degree(s) Received Add RemoveVocational/BusinessNameAddressNumber of Years CompletedDid You GraduateArea of Study and Degree(s) Received Add RemoveHealth Care TrainingNameAddressNumber of Years CompletedDid You GraduateArea of Study and Degree(s) Received Add RemoveOtherNameAddressNumber of Years CompletedDid You GraduateArea of Study and Degree(s) Received Add RemoveDo you have any other experience, training, qualifications, or skills that you feel make you especially suited for work at our Company? YES NO If so, please explain: SKILLSComputer Skills? YES NO Please list all relevant software with which you are proficient(include word processing, graphic, database management, spreadsheet, client accounting, etc.). Add Remove Employment HistoryAre you currently employed? YES NO If so, may we contact your current employer? YES NO List below ALL present and past employment during the past five years, beginning with the most recent employer. Complete all requested information, even if attaching a resume. Attach separate sheets if necessary.Employment Entry 1Dates Employed FromMo:Yr: Add RemoveToMo:Yr: Add RemoveName, Address and Telephone Number of Employer:Type of Business:Position(s) and duties:Name and Telephone Number of SupervisorIf current supervisor, may we contact? YES NO Reason for LeavingCurrent employer?Employment Entry 2Dates Employed FromMo:Yr: Add RemoveToMo:Yr: Add RemoveName, Address and Telephone Number of Employer:Type of Business:Position(s) and duties:Name and Telephone Number of SupervisorIf current supervisor, may we contact? YES NO Reason for LeavingCurrent employer?Employment Entry 3Dates Employed FromMo:Yr: Add RemoveToMo:Yr: Add RemoveName, Address and Telephone Number of Employer:Type of Business:Position(s) and duties:Name and Telephone Number of SupervisorIf current supervisor, may we contact? YES NO Reason for LeavingCurrent employer?Military ServiceHave you obtained any special skills or abilities as the result of service in the military? YES NO If yes, please describe: Personal References Please list at least two (2) persons NOT related to you who have known you for at least (5) years.NamePhoneAddressNamePhoneAddressEmployment References List below 3 persons NOT related to you who have knowledge of your work performance within the last three years.NamePhoneAddressOccupationNo. of years acquainted:NamePhoneAddressOccupationNo. of years acquainted:NamePhoneAddressOccupationNo. of years acquainted:APPLICANT’S STATEMENT (Please read carefully, initial each numbered paragraph as read, and sign below)I certify that all the information I have given on this application is true and correct to the best of my knowledge and that I have not knowingly withheld any information that might adversely affect my chances for employment. I further certify that I have personally completed this application. I understand that failure to provide complete information or any misrepresentation in any information that I have provided to the Company may result in no offer of employment or to termination of employment if I am employed, regardless of the time elapsed before discovery.(Required)I certify that all the information I have given on this application is true and correct to the best of my knowledge and that I have not knowingly withheld any information that might adversely affect my chances for employment. I further certify that I have personally completed this application. I understand that failure to provide complete information or any misrepresentation in any information that I have provided to the Company may result in no offer of employment or to termination of employment if I am employed, regardless of the time elapsed before discovery.I understand that in the event that I am hired by the Company, my employment with the company will be at-will, will be for no definite or determinable period, and that either I or the Company can end the employment relationship at any time, with or without cause or advance notice. I understand that the Company may modify the terms of my employment at any time, with or without cause or notice. I understand an agree that no promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company’s designated representative.(Required)I understand that in the event that I am hired by the Company, my employment with the company will be at-will, will be for no definite or determinable period, and that either I or the Company can end the employment relationship at any time, with or without cause or advance notice. I understand that the Company may modify the terms of my employment at any time, with or without cause or notice. I understand an agree that no promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company’s designated representative.I understand that any offer of employment is contingent upon a satisfactory check on my background, which may require me to sign one or more additional authorizations permitting the Company or authorized third parties to conduct background checks and/or credit checks, but only to the extent permitted by law. I further understand that any authorization for such checks that I am asked to sign will be accompanied by written information about my rights with regard to such checks, and that if I fail to provide the required signed authorization, my offer of employment may be rescinded.(Required)I understand that any offer of employment is contingent upon a satisfactory check on my background, which may require me to sign one or more additional authorizations permitting the Company or authorized third parties to conduct background checks and/or credit checks, but only to the extent permitted by law. I further understand that any authorization for such checks that I am asked to sign will be accompanied by written information about my rights with regard to such checks, and that if I fail to provide the required signed authorization, my offer of employment may be rescinded.I understand that the Company is committed to maintaining a drug and alcohol free work place. Accordingly, I may be subject to a pre- employment blood test, urinalysis or other drug/alcohol screening. I further understand that if employed, I may be subject to such a drug and alcohol screening if the Company has reasonable suspicion to believe that I am under the influence of a drug or alcohol or under certain circumstances, to random drug testing if I am employed in a safety-sensitive position. I understand and agree that I may be required to provide written consent to such tests as a condition of employment and my refusal to consent will result in no offer of employment, rescission of any offer of employment already made or, if already employed, termination of employment.(Required)I understand that the Company is committed to maintaining a drug and alcohol free work place. Accordingly, I may be subject to a pre- employment blood test, urinalysis or other drug/alcohol screening. I further understand that if employed, I may be subject to such a drug and alcohol screening if the Company has reasonable suspicion to believe that I am under the influence of a drug or alcohol or under certain circumstances, to random drug testing if I am employed in a safety-sensitive position. I understand and agree that I may be required to provide written consent to such tests as a condition of employment and my refusal to consent will result in no offer of employment, rescission of any offer of employment already made or, if already employed, termination of employment.I have placed my signature in the space provided below only after I have completed the entire form to the best of my ability and have carefully read the foregoing statements.(Required)I have placed my signature in the space provided below only after I have completed the entire form to the best of my ability and have carefully read the foregoing statements.Upload Your ResumeUpload your resume in .pdf, .doc or .docx formatAccepted file types: pdf, doc, docx, Max. file size: 25 MB. Signature(Required)Date(Required) Month Day Year
