Employment

Position applied for
Date of application
Date Format: MM slash DD slash YYYY
Name
Social Security#
Address
Telephone #
Mobile Phone #
Email Address

Emergency Contact Information
Name
Relationship
Address
Phone #
Are you legally eligible for employment in this country?
- Yes
- No
Date available for work
Date Format: MM slash DD slash YYYY
What is your desired salary?
Type of employment desired
- Permanent
- Substitute
Referral Source
- Advertisement
- Employee
- Relative
- Walk-in
- Other
Other Referral Source
Name of source if applicable
Do you own a vehicle?
- Yes
- No
Driver's License number if driving is required
State
Educational Background
High School, College, Other
Name and location Number of years completed Did you graduate? If yes diploma received Course of study

Skills and Qualification
Summarize any traning, skills, license and/or certificated that may qualify you as being able to perform job-related functions in the position for which you are applying.

Employment History
Provide the following information of your past three employers, assignment or volunteer activities, starting with the most recent.
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Employer
Phone #
Job Title
Address
Immediate Supervisor
Reason for Leaving
Summarize the nature of work performed and responsibilities
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Employer
Phone #
Job Title
Address
Immediate Supervisor
Reason for Leaving
Summarize the nature of work performed and responsibilities
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Employer
Phone #
Job Title
Address
Immediate Supervisor
Reason for Leaving
Summarize the nature of work performed and responsibilities

References
List the names and telephone numbers of three references who are NOT related to you.
Name Telephone Number of years known

Applicant Statement
I certify that all information I have provided in order to apply for and secure work with the employer is true ,complete and correct. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references(personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

If I am hired, I understand that I am free to resign anytime, with or without cause and with 2 weeks prior notice, and the employer reserves the right to terminate my employment at anytime, with or without cause and with and without prior notice, except as maybe required by law.This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurance to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an 1-9 Form in this regard.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read,fully understand and accept all terms of the foregoing APPLICANT STATEMENT.
Signature of Applicant*
Date
Date Format: MM slash DD slash YYYY

Emergency Contact Information

Skills and Qualification

Employment History

References

Applicant Statement

Accreditations

Hours

Hours

Contact

Connect

Name and location	Number of years completed	Did you graduate? If yes diploma received	Course of study

Name	Telephone	Number of years known