Fill and Sign the Nonexempt Form

APPLICATION FOR EMPLOYMENT Position applied for: Clerical Exempt Executive Non-Exempt Other Applying For: Full-time Part-time Temporary Specific Shift Date Available: ______________________________ Name: ____________________________________________________________ Last First Middle Address: __________________________________________________________ Street City State Zip Code Telephone: Home (____) ____-____ When can we reach you at this number? ____ a.m./p.m. Other (____) ____-____ When can we reach you at this number? ____ a.m./p.m In case of emergency, please contact: ________________________ Phone: (____) ____-____ Are you legally eligible to work in the United States? Yes No Are you over 18 years of age? Yes No (Employment is subject to verification of minimum legal age.) Complete only if driving is a job requirement: Do you have a valid driver’s license? Yes No License Number __________________ State ____ Have you filed an application at {Enter Name of Company} before? Yes No If yes, give dates: __________________ Have you been employed by {Enter Name of Company}before? Yes No Name of any relatives employed by Enter Name of Company}: ________________________ What prompted your application? ________________________ COMPLETE EDUCATION RECORD School Name and Location of School Highest Grade Completed Did you Graduate Degree Received Course of Study High School College Business/ Trade School Other List other specific skills, honors, and awards: _________________________________________________________ List memberships in job-related organizations or associations:_________________________________________________________ List Computer Programming Language(s):_________________________________________________________ Check any of the following in which you have training or experience: Typewriter: ____ WPM Dictaphone PBX/Switchboard Shorthand: ____ WPM Calculator Other ___________ Employment History – Starting with most recent Employer: Employed From: To: Address: Supervisor: Phone: Hours worked/week: Starting Salary: Position: Last Salary: Primary Duties: May we contact this employer? Yes No Supervisor’s Phone: Reason for Leaving: Employer: Employed From: To: Address: Supervisor: Phone: Hours worked/week: Starting Salary: Position: Last Salary: Primary Duties: May we contact this employer? Yes No Supervisor’s Phone: Reason for Leaving: Use additional sheets if necessary Professional References Name Place of Employment/Title Phone PERSONAL DATA Number of days missed on last job during past year? ____ Explain: _________________________________________________________ __________________________________________________________________________________________________________________ Have you ever been convicted of a felony or misdemeanor? (Other than a traffic violation) Yes No If yes, explain: _________________________________________________________ NOTE: Convictions are not an automatic bar to employment. Each case is considered on its individual merits and the type of work applied for. However, false statements or withholding information will result in your being barred from appointment or removal from employment. I certify that the information contained in this application is correct to the best of my knowledge, and I understand that falsification of this information is grounds for disqualification for or dismissal from employment. If I accept employment with {Insert name of company}, I will not do so in reliance of any representations that are not made in writing. I hereby authorize {Insert name of company}, to investigate my past and present work, character, education, military and police records to ascertain any and all information that may be pertinent to my employment qualifications. The release in any manner of any and all information is authorized whether such information is of record or not. I do hereby release all persons, firms, agencies or companies from any and all damages resulting from furnishing such information. In consideration of my employment, I agree to conform to the rules, regulations, and policies that the company may periodically promulgate, withdraw or modify. I understand that work schedules and duties may be modified from time to time at the discretion of the company and that alternate position functions and/or positions may be assigned. I understand that I am required upon employment to serve a probationary period; and if my performance is deemed unsatisfactory, I may be terminated at any time. If hired, I will submit the documentation necessary to verify my eligibility for employment. Applicant Signature: _________________________________ Date: _____