APPLICATION for EMPLOYMENT 
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

(PLEASE PRINT)
Location applied for

	Date of Application	
Position(s) applied for

	Days and Hours of Availability	

EMPLOYEE who referred you to us?________________________________

Last Name (Maiden Name if applicable)

	First Name	Middle Initial	
Address (number/street,…)

	Town/City	State and Zip Code
	
Telephone number (home)	(Cell)	Email

									(circle one)
If you are under 18 years of age, can you provide required proof of your
eligibility to work?								YES	NO

Have you ever filed an application for employment with us before?	YES	NO
If you answered YES, When?___________________________and
Which location(s)?______________________________________

Have you ever been employed with us before?				YES	NO
If you answered YES, When?___________________________and	
Which location(s)?______________________________________	page 1 of 5

   Are you currently employed?						   YES	   NO
If you answered YES, May we contact your employer?			YES	NO

  Are you prevented from lawfully becoming employed in this country
because of a Visa or Immigration status?				YES	NO
Note: Proof of citizenship or immigration status will be required upon employment

On what date would you be available to work?			        __________

Are you available for work:	Full time	Part time	Shift work	Temporary
(Circle those that apply)

Are you currently on “lay-off” status and subject to recall?		YES	NO

Can you travel if your job requires it?					YES	NO

EMPLOYMENT EXPERIENCE
Attach resume or start with your current or last job, include any job related military service assignments and volunteer activities.  You may exclude organizations that indicate sex, race, religion, national origin, age, ancestry, handicap, or other protected status.

Employer

	Dates Employed (from             to)	Job Title	Supervisor	
Address	Hourly Rate/Salary
(starting       final)	Work Performed

		
Phone
	Reason for leaving

	

		

Employer

	Dates Employed (from             to)	Job Title	Supervisor

	
Phone
	Reason for leaving

	

		

Employer

	Dates Employed (from             to)	Job Title	Supervisor	
Address	Hourly Rate/Salary
(starting      final)	Work Performed

		
Phone
	Reason for leaving

	

		

Special skills and qualifications:								

EDUCATION
Attach resume or fill in the following

	Elementary School	High School	Undergraduate
College/University	Graduate/
Professional	
School name and location

Number of years completed					
Diploma/Degree
					
Describe any honors you received	

	
	
Describe any specialized training, apprenticeship, skills or extracurricular activities					

State any additional information you feel may be helpful to us in considering your application:  _________________________________________________________________

Indicate any foreign languages you can speak, read, and/or write:
	Fluent	Good	Fair	
Speak				
Read				
Write				

List professional, trade, business or civic activities and office held.
You may exclude memberships, which would reveal sex, race, religion, national origin, age, ancestry, handicap, or other protected status.________________________________
________________________________________________________________________

REFERENCES
Give name, address, telephone number or email of three references including at least one who is a past employer.
1.________________________________________________________________

2.________________________________________________________________

3.________________________________________________________________

Have you ever had any job related training in the United States Military?
YES	NO	If YES, please describe:___________________________________
_________________________________________________________________ 

Are you physically or otherwise unable to perform the duties of the job for which you are applying?								YES	NO
If YES, please describe:______________________________________________

APPLICANT’S STATEMENT
.  I certify the answers given herein are true and complete to the best of my knowledge
.  I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
.  This application for employment shall be considered active for a period of time not to exceed 45 days.  Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.
.  I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause.  It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized execution of this organization.
.  In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.  I understand, also, that I am required to abide by all rules and regulations of the employer.

                                 ____________________________        ____________
                                        Signature of Applicant                            Date	
empapp.doc