APPLICATION FOR EMPLOYMENT

TO APPLICANT: Federal and State Laws require that all applications be considered without regard to race, religion, color, sex, age, marital status, sexual orientation, disability or national origin. Those applicants requiring reasonable accommodation to the application and/or interview process should notify the Administrator of the Facility.

Name (Last, First, Middle)
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Telephone Number Telephone Number - ### - ### ####
Other Contact Number Other Contact Number - ### - ### ####
If you are under 18 and it is required, can you furnish a work permit

If you are under 18 and it is required, can you furnish a work permit Yes No
Are you a U.S. citizen or legally authorized to work in the United States

Are you a U.S. citizen or legally authorized to work in the United States Yes No
Position(s) Applied for
Position(s) Hours

Position(s) Hours Full-Time Part-Time
For which schedules are you available?

For which schedules are you available? Weekdays Weekends Evenings Nights Overtime
If part time specify days/hours available
Desired Wage
Are you able to meet the attendance requirements of the position

Are you able to meet the attendance requirements of the position Yes No
Have you ever been employed here before

Have you ever been employed here before Yes No
If yes, give start and end dates
Do you have any relatives or friends who work for the Facility?

Do you have any relatives or friends who work for the Facility? Yes No
Have you ever been convicted of a felony

Have you ever been convicted of a felony Yes No
If yes, please provide date(s) and details
If the job requires, do you have the appropriate valid driver’s license

If the job requires, do you have the appropriate valid driver’s license Yes No
Chauffeur’s License

Chauffeur’s License Yes No
Education
School 1 (Name, City/State, Course of Study, Years Completed, Degree)
School 2 (Name, City/State, Course of Study, Years Completed, Degree)
School 3 (Name, City/State, Course of Study, Years Completed, Degree)
School 4 (Name, City/State, Course of Study, Years Completed, Degree)
If your school records are in a different name than above, please enter that name here:
Skills and Qualifications
Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.
Employment History

Provide the following information of your past and current employers, starting with the most recent. Explain any gaps in employment in comments section below.
Employer 1 (Name, Phone, Address)
Dates Employed 1 (Start Date, End Date)
Title/Salary 1 (Starting Job Title, Ending Job Title, Starting Salary, Ending Salary)
Immediate Supervisor and Title 1
Reason for Leaving 1
Summarize the Type of Work Performed & Job Responsibilities 1
May We Contact for Reference?

May We Contact for Reference? Yes No
Employer 2 (Name, Phone, Address)
Dates Employed 2 (Start Date, End Date)
Title/Salary 2 (Starting Job Title, Ending Job Title, Starting Salary, Ending Salary)
Immediate Supervisor and Title 2
Reason for Leaving 2
Summarize the Type of Work Performed & Job Responsibilities 2
May We Contact for Reference?

May We Contact for Reference? Yes No
Employer 3 (Name, Phone, Address)
Dates Employed 3 (Start Date, End Date)
Title/Salary 3 (Starting Job Title, Ending Job Title, Starting Salary, Ending Salary)
Immediate Supervisor and Title 3
Reason for Leaving 3
Summarize the Type of Work Performed & Job Responsibilities 3
May We Contact for Reference?

May We Contact for Reference? Yes No
Employer 4 (Name, Phone, Address)
Dates Employed 4 (Start Date, End Date)
Title/Salary 4 (Starting Job Title, Ending Job Title, Starting Salary, Ending Salary)
Immediate Supervisor and Title 4
Reason for Leaving 4
Summarize the Type of Work Performed & Job Responsibilities 4
May We Contact for Reference?

May We Contact for Reference? Yes No
Comments including explanation of any gaps in employment
References

List name and telephone number of three business/work references who are not related to you.
Reference 1 (Name, Phone, No. of Years Known)
Reference 2 (Name, Phone, No. of Years Known)
Reference 3 (Name, Phone, No. of Years Known)
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. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to terminate the application process or employment. I expressly authorize, without reservation, the employer and its representatives to contact and obtain information from all references, employers, public agencies, licensing authorities, and educational institutions, and to otherwise verify the accuracy of all information provided by me in this application, resume, and/or job interview. I specifically authorize a Criminal Background Check. I hereby, waive any and all rights and claims I may have regarding the employer and its representatives for seeking, gathering, and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

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 of employment on a basis of sex, marital status, race, age, creed, national origin, or the presence of disabilities.

If I am hired, I understand that this application does not constitute an agreement or contract for employment for any specified period or definite duration. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard.

I certify that I have read, fully understood and accept all terms of the foregoing Applicant Statement.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT

Education

Skills and Qualifications

Employment History

References

Applicant Statement