Employment Application Employment Application If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. Personal Information First Name * Middle Name * Last Name * Address 1 * Address 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Postal Code * Phone (Home) * Phone (Alternate) Email * Are you 18 years or older? * Are you legally authorized to work in the United States? * Employment Desired Position * Date available to start * Have you ever applied for employment with our company before? * YesNo Have you ever worked for our company before? * YesNo If yes, please provide previous dates of employment. Education High School Years of High School Completed 9101112 Did you graduate? (High School) YesNo Diploma/Degree/Certificate (High School) Technical School Years of Technical School Completed 1234 Did you graduate? (Technical School) YesNo Diploma/Degree/Certificate (Technical School) College Years of College Completed 1 2 3 Did you graduate? (College) YesNo Diploma/Degree/Certificate (College) Special Skills and Additional Training Please describe any special job-related skills or other qualifications that relate to the position for which you are applying. Do not include experiences which would indicate race, color, creed, religion, sex, ancestry, familial status, sexual orientation, national origin, marital status, Vietnam era veteran status, special disabled veteran status, status with regard to public assistance, membership or activity in a local commission, disability or age, family or ancestry. Please describe any special skills or additional training Employment History (Please begin with your current or most recent employer) Employer #1 Dates of Employment Name and Address of Employer Position and Brief Description of Duties Hourly Wage Reason for Leaving Employer #2 Dates of Employment Name and Address of Employer Position and Brief Description of Duties Hourly Wage Reason for Leaving Employer #3 Dates of Employment Name and Address of Employer Position and Brief Description of Duties Hourly Wage Reason for Leaving The following requested information is voluntary and confidential. It will be kept separately from your application and any subsequent personnel file. We collect this information for the sole purpose of creating and maintaining Equal Employment Opportunity and Affirmative Action records. We appreciate your cooperation with our EEO/AA efforts. Sex MaleFemale Race African American (Black) - All persons having origins in any of the Black African racial groups: not of Hispanic origin.Asian or Pacific Islander - All persons having origins in any of the original peoples of the Far East. Southeast Asia, the Indian subcontinent of the Pacific IslandsCaucasian (White, not Hispanic origin) - All persons having origins in any of the original peoples of Europe, North Africa, or the Middle EastHispanic - All persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of raceNative American (American Indian) or Alaskan Native - All persons having origins in any of the original peoples of North America and who maintain identifiable tribal affiliations through membership, participation or recognition.Other PERSON WITH A DISABILITY An individual a. who has a physical or mental impairment (condition) that materially or more major life activities; or b. who has a record of such impairment; or c. who is regarded as having such an impairment Major life activities may include such activities as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, sitting, standing, lifting, breathing, leaning and working. According to the above definition, are you disabled? YesNo How did you first learn about this position? By submitting, I Agree... “I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing the same to you. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date and payment of my wages and salary, be terminated at any time without prior notice and without cause.”
