Date
MM
DD
YYYY
Name
*
First Name
Last Name
Social Security Number
*
Present Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Secondary Phone
(###)
###
####
Email
*
Position Desired
Date You Can Start
MM
DD
YYYY
Salary Desired
Are you employed now?
If so, may we inquire of your present employer?
Are you legally authorized to work in the U.S.?
Former Employer 1: Name & Address
Former Employer 1: Salary
Former Employer 1: Position
Former Employer 1: Reason for Leaving
Former Employer 2: Name & Address
Former Employer 2: Salary
Former Employer 2: Position
Former Employer 2: Reason for Leaving
Reference 1: Name
Reference 1: Phone
Reference 2: Name
Reference 2: Phone
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 and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from a liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws. I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire. Full Name:
Date
MM
DD
YYYY
