Application for Employment

It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, disability or other protected classifications. Please carefully read and answer all questions. You will not be considered for employment if you fail to completely answer all the questions on this application. All questions must be answered...

PERSONAL DATA

Name (last, first, middle)
Street Address and/or Mailing Addres
Home Telephone Number
Work Telephone Number
Date you can start work
Salary Desired
Do you have a High School Diploma or GED?	Yes No

POSITION INFORMATION

Position applying for
Hours	Full Time Part Time
Shifts	1st 2nd 3rd 4th 5th
Status	Regular Temporary
Are you authorized to work in the U.S. on an unrestricted basis?	Yes No
Have you ever been convicted of a felony? (Convictions will not necessarily disqualify an applicant for employment.)	Yes No
Have you been told the essential functions of the job or have you been viewed a copy of the job description listing the essential functions of the job?	Yes No
Can you perform these essential functions of the job with or without reasonable accommodation?	Yes No

QUALIFICATIONS

	School Name	Degree	Address/City/State
School
Other

SPECIAL SKILLS

REFERENCES

Name	Address/City/State	Phone	Relationship

WORK HISTORY

Job Title #1
Company Name		Address/City/State
Start Date		End Date
Supervisor's Name		Phone Number
Starting Salary		Ending Salary
Reason for Leaving		May we contact your present employer?	Yes No
Duties:

Job Title #2
Company Name		Address/City/State
Start Date		End Date
Supervisor's Name		Phone Number
Starting Salary		Ending Salary
Reason for Leaving		May we contact your present employer?	Yes No
Duties:

Applicant Signature

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the Employer to make an investigation of any of the facts set forth in this application and release the Employer from any liability. The employer may contact any listed references on this application.I acknowledge and understand that the company is an "at will" employer. Therefore, any employee (regular, temporary, or other type of category employee) may resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or without cause, with or without notice to the other party.
Applicant Signature		Date