Federal law prohibits discrimination on the basis of race, color, religion, sex, national origin, age, disability or other protected status. |
| Personal Data |
| Position applied for: |
| Today's Date: |
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Name |
| First
Middle
Last
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Address |
| Street Apt. #
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| City:
State:
Zip Code:
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Phone Number |
| Daytime
Evening
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| *E-mail address |
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Salary Desired $ |
Can you prove that you are eligible for work in the U.S.?
Yes No |
If hired, are you able to get to work and meet attendance requirements every day?
Yes No |
How did you hear about this position?
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If under 18 years of age, can you furnish a work permit if required?
Yes
No
If not please explain:
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Have you been convicted of a felony in the last five years?
Yes
No
If yes please explain:
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Type of employment wanted:
Full Time Part time Temporary |
Date available to start working: |
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| What hours do you prefer to work? |
| Can you work overtime, if required? Yes No |
| Weekends if required? Yes No |
| Please list hours you cannot work: |
| How many days of work or school have you missed in the last year for reasons other than sickness? |
Please Explain:
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| How many days have you been late in the last year? |
Please Explain:
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Education |
| Highest Level of Education Attained: |
Summarize any employment, training or skills that may qualify you for the position you are applying for:
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Employment History |
| Please list your last four employers, starting with the most recent: |
Employer #1
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Address
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Phone
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Job Title/Position
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| Supervisor�s name & title:
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| Reason for leaving:
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Describe Duties:
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Starting Date:
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Ending Date:
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Starting Salary/Hourly Rate:
$ |
Ending Salary/Hourly Rate:
$ |
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Employer #2
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Address
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Phone
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Job Title/Position
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| Supervisor�s name & title:
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| Reason for leaving:
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Describe Duties:
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Starting Date:
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Ending Date:
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Starting Salary/Hourly Rate:
$
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Ending Salary/Hourly Rate:
$
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Employer #3
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Address
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Phone
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Job Title/Position
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| Supervisor�s name & title:
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| Reason for leaving:
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Describe Duties:
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Starting Date:
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Ending Date:
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Starting Salary/Hourly Rate:
$
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Ending Salary/Hrly Rate:
$
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Employer #4
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Address
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Phone
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Job Title/Position
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| Supervisor�s name & title:
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| Reason for leaving:
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Describe Duties:
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Starting Date:
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Ending Date:
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Starting Salary/Hourly Rate:
$
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Ending Salary/Hourly Rate:
$
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Additional Comments:
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Federal law prohibits discrimination on the basis of race, color, religion, sex, national origin, age, disability or other protected status. |
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I
certify that the statements contained herein are true and correct to the best of my knowledge, and I understand that any false statement or omissions by me on this inquiry and any other required document is considered a cause for denial of employment or discharge, whenever discovered.
I understand that this document is an application for employment, and does not constitute an agreement or contract for employment of any length of time. If hired, I have the freedom to quit at any time. The employer also has the right to terminate my employment with or without cause, the exceptions being as required by law.
I authorize the above employer to investigate all information in the above application for employment. The employer has the right to contact previous employers, schools, and other references to verify this information. I release the employer from any liability in gathering this information. I release from liability any companies or institutions supplying this information. After termination of my employment, for whatever reason, I release the above employer from liability for any information supplied to future potential employers.
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| *required |
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