Employment Application

Position you are applying for*

Your Name (first, middle, last)*

Phone Number*

Street Address and/or Mailing Address (Street, City, State, Zip)*

Email Address*

Date you can start work*

Pay Desired*

Do you have a High School Diploma or GED?* Do you have a High School Diploma or GED?* Yes No

Are you interested in Full Time or Part Time?* Are you interested in Full Time or Part Time?* Full Time Part Time

Are you authorized to work in the U.S. on an unrestricted basis?* 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.)* 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 viewed a copy of the job description listing the essential functions of the job?* Have you been told the essential functions of the job or have you 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 accommodations?* Can you perform these essential functions of the job with or without reasonable accommodations?* Yes No

Please list any education or training you feel relates to the position applied for that would help you perform the work, such as schools, colleges, degrees, vocational or technical programs, and military training. (Include School Name, Degree, School Address).*

List any special skills or experience that you feel would help you in the position that you are applying for (leadership, organizations/teams, etc.)*

Please list three professional references not related to you, with full name, address, phone number, and relationship. If you don't have three professional references, then list personal, unrelated references. (Include names, addresses, phone and relationship.)*

Work History: Job Title #1 - Start with your present or most recent employment and work back. Include paid and unpaid positions. Include: Title, Start Date, End Date, Company Name, Supervisor's Name, Phone Number, Address, Your Duties, Reason for Leaving, Starting Salary and Ending Salary.*

Work History: Job Title #2 - Include paid and unpaid positions. Include: Title, Start Date, End Date, Company Name, Supervisor's Name, Phone Number, Address, Your Duties, Reason for Leaving, Starting Salary and Ending Salary.*

Work History: Job Title #3 - Include paid and unpaid positions. Include: Title, Start Date, End Date, Company Name, Supervisor's Name, Phone Number, Address, Your Duties, Reason for Leaving, Starting Salary and Ending Salary.*

Work History: Job Title #4 - Include paid and unpaid positions. Include: Title, Start Date, End Date, Company Name, Supervisor's Name, Phone Number, Address, Your Duties, Reason for Leaving, Starting Salary and Ending Salary.

I certify that the facts set forth in this Application for Employment or Volunteering 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.* I certify that the facts set forth in this Application for Employment or Volunteering 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.* Yes

Applicant's Typed Signature and Today's Date:*