Employee Service Application

Employee Service Application

Please complete all sections. Omissions or false statements may disqualify an application or serve as grounds for dismissal if discovered after hire. All information will be treated in accordance with applicable privacy laws.

Application Details

Date of Application:    Position Applied For:    Location/Department:

Personal Information

Date of Birth:    Social Security Number (last 4 digits for ID verification):

Eligibility & Work Authorization

Are you legally authorized to work in the country where you are applying?   Yes   No

Will you now or in the future require employer sponsorship for work authorization?   Yes   No

Position Information

Available Start Date:    Salary/Hourly Rate Requested:

Employment History (Last Two Employers)

Employer 1

May we contact this employer?   Yes   No

Employer 2

May we contact this employer?   Yes   No

Education

Graduation Date:    Major / Field of Study:

Professional References

Reference 1

Reference 2

Reference 3

Legal Disclosures & Consent

At-Will Employment: I understand that, if hired, my employment is for no definite period and may be terminated at any time by either party with or without cause and with or without notice, unless expressly provided otherwise in a written agreement signed by an authorized representative.

Equal Opportunity: The employer is an equal opportunity employer. Employment decisions are made without regard to race, color, religion, sex, national origin, age, disability, marital status, sexual orientation, or other protected status.

Have you ever been convicted of a felony or misdemeanor that has not been annulled, expunged, or sealed?   Yes   No

Background and Reference Checks: I authorize the employer and its agents to contact prior employers, educational institutions, references, and other entities to verify the information provided and to conduct background checks as permitted by law. I release all parties from liability for providing such information.

I consent to pre-employment drug testing and any medical examinations required for the position, subject to applicable law.   I consent   I do not consent

Applicant Certification & Authorization

I certify that all information provided in this application and any attachments is true, complete, and correct to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts may result in denial of employment or immediate termination of employment if hired. I authorize investigation of all statements contained in this application and release from liability any persons or organizations supplying such information.

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