Job Application Job Application Personal Information First Name * Last Name * Physical Street Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine New Option Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Mailing Address (if different) City (Mailing) State (Mailing) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code (Mailing) Phone # * Best Contact EMAIL Birth Date (MM-DD-YYYY) * Referred By: Relationship: Employment Desired Position Desired * Date Can Start (MM/DD/YYYY) * Salary Desired Special skills, Licenses, Courses, and Training Related to Employment Education History High School * Graduated? * Yes No G.P.A. High School City * High School State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other Educational School Other School Type College Vocational Other Other School City Other School State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Graduated other school type? Yes No Major Studies Former Employment List employers, starting with the most recent. Employer Company Name & Address * Employer Phone # * Dates Employed * Rate of pay * Position & Duties * Reason for Leaving: * Quit Layoff Fire If fired, explain. Supervisor * Employer Company Name & Address Employer Phone # Dates Employed Rate of pay Position & Duties Reason for Leaving: Quit Layoff Fire If fired, explain. Supervisor Employer Company Name & Address Employer Phone # Dates Employed Rate of pay Position & Duties Reason for Leaving: Quit Layoff Fire If fired, explain. Supervisor References 1-Reference Name * Reference Phone # * Employed by: * 2-Reference Name * Reference Phone # * Employed by: * 3-Reference Name * Reference Phone # * Employed by: * (Optional) Additional Personal Information Marital Status Number of Children Can you read? Yes No Can you write? Yes No Can you speak any languages other than English? If so, which? Can you read/write any other languages other than english? Military Experience Have you ever been arrested? Yes No If yes, please explain arrest. Do you have a valid Driver's License? Yes No Do you own a vehicle? Yes No Are you currently in school? Yes No Are you requesting after-school shifts only? Yes No N/A If yes in school, when do you graduate? Will you consent to random drug screens before and throughout your employment? Yes No AVAILABILITY Under each day you are available, list the hours you are available (Time In - Time Out). Example: 8:00 am - 7:00 pm MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY I'm available to work (check all that apply): Holidays Weekends Overtime Extended Hours Part-time (less than 30 hours/week) Authorization of Application I certify that the facts contained in this application are true and complete to the best of my knowledge, and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is writing and signed by an authorized company representative. This waiver does not permit the release or use of disability‐related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws. I hereby declare that I am not disabled in any way which would prevent me from steadily performing all the work applied for in this application. I authorize the company to contact any of my previous employers as well as any reference source I have provided in order to verify the facts and information I have furnished regarding my qualifications and character. I hereby authorize any person(s) having knowledge thereof to privde such information to the company, and I hereby release from liability and agree to hold harmless any person that furnishes such information in good faith. I agree that I will submit to a physical, urinalysis, and/or blood or other examination requested by the company at any time prior to or subsequent to my employment. I authorize the company to supply my employment record in whole or part and in confidence to any employer, insurance agency, or other party with a legal and proper interest, and I hereby release the company from any liability and agree to hold harmless any employee of the company who furnishes such information. I further understand that my employment is for no fixed time and may be discontinued with or without cause of birth and military service. I understand that no employee or officer agent of the company may bind this information by oral or printed statements, including handbooks, benefit books, or bulletins, contrary to the above. I have carefully read the information on this form; I realize I had the opportunity to ask questions and I accept that the information I have signed for is understood. By placing my signature below, I certify that the information I have provided on these pages is complete and true to the best of my knowledge. The falsification of data or omissions of material facts will constitute grounds for dismissal and denial of application. I authorize this application. * YES NO Sign by Typing your FULL NAME * Submit Application
