Form

Employment/Job Application #2

December 14, 2023

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PLEASE PRINT

PERSONAL INFORMATION

Name: _____________________________________ Date: _____________

Address: ___________________________________

City: ____________State: _____ Zip Code: _______ Number: (___) _______

Position desired? ________________________________________________

Can you perform the essential functions of the position for which you are applying?
YES [ ] NO [ ]
If no, please explain. (If you have any question as to what functions are applicable to the position for which you are applying, please ask the interviewer before you answer this question)

______________________________________________________________

When are you available to begin work? ___________________________

Are you legally eligible to be employed in the United States? YES [ ] NO [ ]

(Proof of identity and eligibility will be required upon employment)

Are you over the age of 18 years? YES [ ] NO [ ]

(If no, you may be required to provide authorization to work.)

Have you ever worked for this Company before? YES [ ] NO [ ]

If yes, where? ________ When? (Give dates)__________ Job Title: ______________________

Do you have any relatives or friends who work for the Company? YES [ ] NO [ ] If yes, who and where do they work?

______________________________________________________________

Have you ever done any volunteer work? YES [ ] NO [ ] If yes, describe: (Omit any volunteer work which reflects your race, color, religion, age, sex, sexual orientation, marital status or disabilities)

______________________________________________________________

Are you available to work: DAYS [ ] NIGHTS [ ] WEEKENDS [ ] FULL TIME [ ] If you cannot work full time, please explain:

______________________________________________________________

Days and Hours Available: (If employed, notification must be provided in writing should availability change.)

Day	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
From:
To:

Are you presently employed? YES [ ] NO [ ]

If yes, may we contact your employer? YES [ ] NO [ ]

If presently employed, why are you considering leaving?
______________________________________________________________

Do you belong to any professional, trade, business or civic organizations that deal with the position for which you are applying? YES [ ] NO [ ] If yes, please explain and list offices held: (Omit any organization which reflects your race, color, religion, age, sex, sexual orientation, marital status or disabilities.)

______________________________________________________________

______________________________________________________________

Account for any full month since leaving school (high school or college) that you were not working:

From	To	Reason
Mo/Yr
Mo/Yr
Mo/Yr

EDUCATION

	Name and Location of School	Course of Study	No. of Years Completed	Diploma or Degree Received
High School
College
Vocational or Trade School
Graduate Work

Have you completed any special courses, seminars and/or training directly related to the position for which you are applying? YES [ ] NO [ ] If yes, please describe:

______________________________________________________________

______________________________________________________________

______________________________________________________________

List academic honors, extracurricular activities, offices held, etc. in high school or college: (Omit any which reflects your race, color, religion, age, sex, sexual orientation, marital status or disabilities.)______________________________________________________________

______________________________________________________________

EMPLOYMENT

Start with your current or most recent position

Name of Employer	Phone Number
Full Address (Including Street, City, State & Zip)	Supervisor's Name and Title
Dates Employed From Month/Day/Year To Month/Day/Year
Describe the Work Performed _____________________________________________________________ _____________________________________________________________ _____________________________________________________________
Name of Employer	Phone Number
Full Address (Including Street, City, State & Zip)	Supervisor's Name and Title
Dates Employed From Month/Day/Year To Month/Day/Year
Describe the Work Performed _____________________________________________________________ _____________________________________________________________ _____________________________________________________________
Name of Employer	Phone Number
Full Address (Including Street, City, State & Zip)	Supervisor's Name and Title
Dates Employed From Month/Day/Year To Month/Day/Year
Describe the Work Performed _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

Use an additional sheet of paper if more space is necessary.

PERSONAL REFERENCES

Give three references (not relatives or employers)

Name	Occupation
Full Address (Including Street, City, State & Zip) Street____________________________ City_______State_____ Zip___	Telephone Number ( )
Name	Occupation
Full Address (Including Street, City, State & Zip) Street____________________________ City_______State____ Zip____	Telephone Number ( )
Name	Occupation
Full Address (Including Street, City, State & Zip) Street_________________________ City_____ State_____Zip_____	Telephone Number

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.

IMPORTANT, PLEASE READ AND SIGN

I understand that failure to reveal any prior employer, or giving false or misleading information by me on any part of this Application for Employment can result in disqualification for employment consideration or, if hired, may be grounds for termination from the company or its' subsidiaries. I understand that if I am hired, my employment is for no definite time and may be terminated at any time without prior notice.

Signed: _____________________________________________

Do not write below this line

RESULTS

Employed: YES [ ] NO [ ]

If Yes, Job Title: ________________ Department___________________

Date beginning Employment _________Compensation $_____ per_____

Interviewed by: __________________________ Date: __________