Employment Application

General

Last Name:   First Name:   Middle Initial:

Telephone Number:   Email Address:

Present Address:

City: State: Zip Code:

Permanent Address:

City: State: Zip Code:

 

Were You Ever Employed By Us?    Yes    No

If so, Please Provide Period(s) Employed and Position(s) Held:

Have You Ever Served in the Military:    Yes    No

How Did You Learn About Us?

 

Job Interest

Department of Interest     

Position or Type of Work Desired:  

Second Choice:

Work Schedule Desired:     Full Time        Part Time        Temporary

Date Available to Begin Work:

Wage or Salary Desired:

Are You Willing to Relocate:     Yes        No

Are You Willing to Travel:         Yes        No

Are You Willing to Work Extra Hours, Weekends and Evenings:     Yes        No

 

Personal

If You Have Plead Guilty, No Contest, Had a Suspended Imposition of Sentence, or Have Been Convicted of Any Felony, Please Describe Each: (Convictions are not necessarily a reason for exclusion from consideration for employment)

Are you at least 18 years old:    Yes    No

Provide ONLY the information requested in this employment application form.

Failure to do so will result in disqualification of your application.

 

Education

  Name&Location No of Years Complete Graduated? Grade Major Field of Study Minor Field of Study Scholastic Standing or GPA
High School  Yes No
College  Yes No
University  Yes No
Business, Technical, Other  Yes No

 

Scholastic Honors, Scholarships, Assistantships, Awards, Publications, etc.

 

 Employment History - List Most Recent Employer First

 

 

Company Name:

Company Address:

Dates Employed - From      To

Job Title:

Wage / Salary:

Reason for Leaving:

Supervisor's Name: Supervisor's Title:

Telephone: May We Contact:    Yes    No

Provide a Brief Description of Your Work and Responsibilities:

Company Name:

Company Address:

Dates Employed - From      To

Job Title:

Wage / Salary:

Reason for Leaving:

Supervisor's Name: Supervisor's Title:

Telephone: May We Contact:    Yes    No

Provide a Brief Description of Your Work and Responsibilities:

Company Name:

Company Address:

Dates Employed - From      To

Job Title:

Wage / Salary:

Reason for Leaving:

Supervisor's Name: Supervisor's Title:

Telephone: May We Contact:    Yes    No

Provide a Brief Description of Your Work and Responsibilities:

Company Name:

Company Address:

Dates Employed - From      To

Job Title:

Wage / Salary:

Reason for Leaving:

Supervisor's Name: Supervisor's Title:

Telephone: May We Contact:    Yes    No

Provide a Brief Description of Your Work and Responsibilities:

Special Skills

Computer Software Applications:

Professional Registrations:

Skills:  

  Adding Skills    Calculator    Dictation Equipment    Data Entry  Typing WPM:    Shorthand

Please List Any Other Applicable Skills:

Activities

List Organizations of Which You Are a Current or Former Member: (Membership in Religious, Ethnic or Foreign Organizations Will Not Be Used for Purposes of Discrimination)

 

High School & College Activities (Include if Applicable, Office or Position Held)

 

Professional & Technical Organizations  (Include if Applicable, Office or Position Held)

 

Civic & Recreational Activities

 

References

Please List Three Personal References Whom We May Contact:

Name:

Telephone Number:

Address:

Name:

Telephone Number:

Address:

Name:

Telephone Number:

Address:

Applicant Statement and Acknowledgement

I certify that, to the best of my knowledge, the information given in this application and any attachments are true and correct. I understand that any incorrect, incomplete, false or misleading statement, answer or information will subject my application to disqualification from further consideration, or if employed, may subject me to termination of employment. I hereby agree that the Company may investigate my qualifications with previous employers, personal references and other background security or criminal conviction records. If employed, I agree to execute a confidentiality/assignment of invention agreement, in consideration of such employment. I understand my employment with the Company is terminable at-will and would not be for any fixed period of time, and I may resign at any time for any reason or the Company may terminate my employment at any time for any reason with or without notice, and that this application is not and is not intended to be a contract for continued employment. I understand that according to law all individuals who are hired must as a condition of employment produce certain documentation to verify their legal authorization to work in the US. As a consequence, I understand that offer of employment, (and continued employment) would be contingent on my ability to produce the required documentation within the time period required by law. I have read and understand all of the provisions of this statement and acknowledgment. By signing this application, I hold the Company harmless from any result of the reference check. I hereby authorize and release from liability all former employers, educational institutions, law enforcement agencies or other governmental agencies to provide or release information regarding my employment, education, criminal conviction record, credit history, drivers license and motor vehicle records that may be in their possession, to the Company or its agents. I further understand that an offer of employment (and continued employment) is conditioned upon several criteria, including my satisfactorily passing certain laboratory test (including test for substance abuse) which may be required by the Company.

 

Please Type Full Name Here:

Date: