Fill and Sign the Work Application Form

EMPLOYMENT APPLICATION Applications are considered without regard to race, color, religion, sex, national origin, age, marital or veteran status, or the presence of a non-job-related medical condition or handicap. PERSONAL INFORMATION: Date       Start Date       Full Time Part Time Temporary Referral Source       Name:       Business Name:       Form of Entity:       Street Address:       Phone:       City/State/Zip:       SSN:       EMPLOYMENT ELIGIBILITY: To be employed by ______________________________ , you must meet certain state and federal employment eligibility requirements. These include (but are not limited to) United States citizenship or authorization to work in this country, and no felony convictions (for some jobs). Please answer the following questions. 1. Are you legally qualified to work in the United States? YES No If no, please explain details in full:                   Have you, or any person or entity with whom you have been associated with, filed for bankruptcy, been declared bankrupt or insolvent or been the subject of any receivership proceedings within the last 7 years? Yes No If Yes, please provide full details, including dates, places, amounts involved and disposition:                   EDUCATION: Schools/Colleges Attended: # Years Year Grad Degree                                                                                                                         - 1 - EMPLOYMENT/WORK EXPERIENCE: Start with your present or most recent position. Include military service assignments and volunteer activities. Exclude organization names that indicate race, color, religion, sex or national origin. Employer:       Job Title:       Supervisor:       Street Address:       City/State/Zip:       Phone:       Describe Duties/Responsibilities/Accomplishments:             Reason for Leaving:       Dates of Employment (Month/Year): From       To       Employer:       Job Title:       Supervisor:       Street Address:       City/State/Zip:       Phone:       Describe Duties/Responsibilities/Accomplishments:             Reason for Leaving:       Dates of Employment (Month/Year): From       To       Employer:       Job Title:       Supervisor:       Street Address:       City/State/Zip:       Phone:       Describe Duties/Responsibilities/Accomplishments:             Reason for Leaving:       Dates of Employment (Month/Year): From       To       MILITARY SERVICE : (A copy of a report of separation from the Armed Services may be required) 1. Are you a veteran? YES NO If yes, list type of discharge: __________________________ 2. Dates of service (From/To) __________________________ 3. Are you a surviving spouse of a veteran who has not remarried? YES NO Are you a surviving orphan of a veteran? YES NO If yes, dates of service for veteran: __________________________ BUSINESS REFERENCES: Please provide individual and company names, position, addresses and phone numbers for 3 business references. Name:       Company:       - 2 - Street Address:       Position:       City/State/Zip:       Phone:       Name:       Company:       Street Address:       Position:       City/State/Zip:       Phone:       Name:       Company:       Street Address:       Position:       City/State/Zip:       Phone:       PERSONAL REFERENCES: Please provide names, addresses, phone numbers, relationship and how long known for 3 personal references. Name:       Relationship:       Street Address:       How long:       City/State/Zip:       Phone:       Name:       Relationship:       Street Address:       How long:       City/State/Zip:       Phone:       Name:       Relationship:       Street Address:       How long:       City/State/Zip:       Phone:       LANGUAGE SKILLS : Check any which apply to you. Multilingual (Specify languages)       Sign Language LICENSING/CERTIFICATION: If a license or certification is required or related to the position for which you are applying, complete the following: License Date Issued Date Expires Issuer/Location of Issuing Authority License No. SPECIAL SKILLS: Describe any special skills or qualifications for this work: - 3 -                                     I AUTHORIZE any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information they may have, personal or otherwise, with regard to any of the subjects covered by this application, and I release such parties from all liability from any damages which may result from furnishing such information to you. I CERTIFY that the above answers are true and complete to the best of my knowledge. I authorize _______________________ , to investigate any statement contained in this application, and to obtain a credit report on me (and my company if this application is for reselling by a company) as necessary to determine my qualifications. I understand that this application is not and is not intended to be any kind of contract or agreement. In the event of employment, I understand that any false or misleading information given in my application, correspondence, discussions or interview may result in refusal to hire or immediate termination if hired. I understand also, that I am required to abide by all rules, regulations and policies of ______________________ . Signed: _______________________________________________________ Date:       FOR ________________ USE ONLY: Arrange Interview: Yes No Date:       Place:       Remarks:                         Approved: Yes No Date:       By:       - 4 -