Employment Application

This is a Drug-Free Workplace Offering Equal Employment Opportunities. Applications are received and employees are hired without regard to race, creed, color, sex, religion, age, genetic information, national origin, physical or mental handicap, disability, veteran’s status, citizenship status, or any other protected classes under state, local or county regulations. The receipt of this application does not mean that job openings exist and does not obligate us in any way. We appreciate your interest in our organization.

Last Name:* First Name:* Middle Initial: Home Phone:*

Address:* Cell Phone:

City:* State:* Zip:*

Email* Preferred method of contact:  Home Phone Cell E-mail Other

Your Work History And Any Employment Gaps

Must be completed even when accompanied by resume. List most recent or current job first. You must include any gaps in employment, with a full explanation and dates for the gap. You must also provide a complete work history for a minimum of 15 years.

Employer:

Address (City, State, Zip):

Job Title

 Resigned or Terminated
State reason:

From (mm/yy):

To (mm/yy):

Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings:

Start:

Final:

Summary of Work Performed & Job Responsibilities:

Supervisor’s Name:

Employer:

Address (City, State, Zip):

Job Title

 Resigned or Terminated
State reason:

From (mm/yy):

To (mm/yy):

Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings:

Start:

Final:

Summary of Work Performed & Job Responsibilities:

Supervisor’s Name:

Employer:

Address (City, State, Zip):

Job Title

 Resigned or Terminated
State reason:

From (mm/yy):

To (mm/yy):

Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings:

Start:

Final:

Summary of Work Performed & Job Responsibilities:

Supervisor’s Name:

More of Your Work History And Any Employment Gaps

Employer:

Address (City, State, Zip):

Job Title

 Resigned or Terminated
State reason:

From (mm/yy):

To (mm/yy):

Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings:

Start:

Final:

Summary of Work Performed & Job Responsibilities:

Supervisor’s Name:

Employer:

Address (City, State, Zip):

Job Title

 Resigned or Terminated
State reason:

From (mm/yy):

To (mm/yy):

Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings:

Start:

Final:

Summary of Work Performed & Job Responsibilities:

Supervisor’s Name:

Employer:

Address (City, State, Zip):

Job Title

 Resigned or Terminated
State reason:

From (mm/yy):

To (mm/yy):

Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings:

Start:

Final:

Summary of Work Performed & Job Responsibilities:

Supervisor’s Name:

Employer:

Address (City, State, Zip):

Job Title

 Resigned or Terminated
State reason:

From (mm/yy):

To (mm/yy):

Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings:

Start:

Final:

Summary of Work Performed & Job Responsibilities:

Supervisor’s Name:

Tell Us About Yourself

You must answer every question on this application. If a question does not apply, put “N/A.” Please print.

What position are you applying for?

What is your salary expectation? $ When can you start work? (Date):

How were you referred to us? (If you were referred by a person, please provide the name):

Have you completed an application here before?  Yes No If yes, date/location:

Are you available to work (Check any that apply):  Full-time Part-time Temporary Nights Weekends

Are there any days or times during the week that you are not available to work?  Yes No
(Reasonable accommodation of religious needs that do not create an undue hardship will be considered, if applicable)

If yes, please list the days/times you are not available to work:

If necessary, can you provide proof that you are over any minimum work age requirement?  Yes No

Are you willing to work overtime?  Yes No      Do you have steady transportation to work?  Yes No

Can you travel, if required?  Yes No    What percentage of time?

Are you on a layoff and subject to recall?  Yes No    May we contact your present employer?  Yes No

How much time have you lost from work during the past 12 months?

Are you now, or do you expect to be, engaged in any other business or employment while working here?  Yes No

If yes, please explain:

Are you presently an officer, employee, or employer of another business in our industry or with whom we compete?  Yes No

If yes, please explain:

Have you ever been terminated or asked to resign from a job?  Yes No

If yes, please explain:

Why do you desire to make a change?

Are you legally eligible to work in the United States?  Yes No

What three things are most important to you in a job? 1) 2) 3)

What three adjectives best describe you? 1) 2) 3)

What type of work do you most enjoy?

Why do you want to work here?

Have you ever been a customer of ours?  Yes No    If yes, what services did you receive?

Tell Us About Your Special Skills And Qualifications

List any special skills, training, experience, certifications, or licenses that may be relevant to this position or our company:

List any professional, trade, business, or civic activities or offices held that would relate to working here:

List any foreign languages that you fluently speak, read, and/or write that would relate to working here:

List software programs that you are proficient in:

Your Educational Background

Schooling Did you
graduate?
Years
completed
Degree received and
Major subject
Name of School Location
High School or GED  Yes No
Trade, Business, or
Correspondence
 
College  
Graduate School  

Tell Us About Your Driving Record

Necessary for positions that may require use of a personal or company vehicle for work

Do you hold a valid and unexpired Driver’s License that is not currently suspended or revoked?  Yes No

If yes, provide the state:

Have you been convicted of any moving violation(s) in the last 5 years?  Yes No

If yes, give date(s) and explanation of each:

Military Service

Branch of Service:     Rank at Discharge (if applicable):

List Duties and Special Training and/or Skills:

Non-Compete Agreement

Are you currently subject to a Non-Compete Agreement or Restrictive Covenant that would prohibit you from working at our company in the position for which you are applying?  Yes No

If yes, provide a copy of the agreement and state the name of the company:

Tell Us About Your Past

Answering “yes” to any of these questions is not an automatic bar to employment.

Have you ever been disciplined or terminated from any job for an act of violence, harassment, discrimination, ethical breach or theft?  Yes No

If yes, explain the circumstances, employer, and date

Have you ever been a defendant in a civil action for an intentional tort? (e.g. assault, battery, false imprisonment, infliction of emotional distress, tortuous interference with a business relationship, defamation, invasion of privacy, fraud and misrepresentation, abuse of process and malicious prosecution or others)  Yes No

If yes, provide an explanation of the nature of the intentional tort, the date of the action, the location, and the disposition or outcome:

Have you ever had any professional license or certificate suspended or revoked (e.g., pest control operator’s license, law license, real estate license, etc.)?  Yes No

If yes, list the professional license(s) and/or certificate(s) that were suspended or revoked and state when and why the license(s) and/or certificate(s) were suspended or revoked:

Are you currently under investigation or wanted by any law enforcement agency?  Yes No

If yes, by what law enforcement agency and for what reason?

Tell Us About Any Records

Have you ever been convicted of, received a sentence for, pled nolo contendere (no contest) to, been placed on probation, or fined by any judicial or quasi-judicial body for a crime, other than a minor traffic violation? (Arrest records and juvenile, sealed and expunged records should not be disclosed. Any other criminal record not disclosed by you may be considered falsification of this application, which may result in revocation of your employment offer or termination of your employment. Also, in accordance with any state or federal regulations, you may be required to provide copies of any criminal records. See below for specific instructions related to the state in which you are applying for employment. If the state in which you are applying for employment is not listed, answer this question as worded.)
Answering “yes” to this question is not an automatic bar to employment.
 Yes No

If yes, describe the details of the conviction/offense, the sentence for the conviction/offense, the date of the conviction/offense (month and year), and your rehabilitation since then:

Agreement and Release

For the purpose of this agreement and release, the organization that has provided you with this application is referred to as “the company,” “this company,” or “you” in the following paragraphs:

The facts set forth above in my application for employment are true and complete. I understand that false statements or omission of information on this application (even if discovered after employment) or any other employment form may lead to dismissal or denial of employment. You are hereby authorized to make any investigation of my personal history, financial, criminal, credit, and motor vehicle records through any investigative or credit agencies or bureaus of your choice. You are also authorized to administer a personality profile or other pre-employment tests and verify my background. A criminal record or sentence is not an automatic disqualification for employment. I agree to submit to any drug or alcohol testing prior to or after employment, and I agree to submit to a medical evaluation, if required. I consent to the release of any or all medical information or records deemed necessary to determine my capability to perform the essential job functions of the position for which I may hold.

In making this application for employment, I also understand that an investigative consumer report may be made whereby information is obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted. I also acknowledge that the company may conduct a search for information about me that is in the public domain including, but not limited to, information on social networking sites. In exchange for the consideration of my employment application by this company, I hereby release and forever discharge this company (including its directors, officers, employees, and agents) and my past and/or present employers (including their directors, officers, employees, and agents) from any liabilities which may result from an investigation of my past and/or present employment or from the disclosure of such information. I authorize the use of any information in this application to verify my statements, and I authorize past employers, doctors, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record.

I understand that if my application is accepted and if I am hired, that employment with this company at all times is employment “at will.” It is further understood that this “at will” relationship may not be changed by any written document, verbal statements, or by conduct unless an authorized executive of this company specifically acknowledges such change. I further understand that my “at will” employment may be terminated at any time by this company or myself and includes no guarantee, contract, or promise of employment for any specific length of time. I understand that the first 90 days of employment is a new-hire introductory period.
Submission of this application does not imply that you will be hired.

I have read, understand, and by my signature consent to these statements:

Signature of Applicant:    Date:

Your Emergency Contact

In Case of an Emergency, I Authorize You to Contact:

Name     Telephone Number: