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Date:*
Last Name:*    First Name:*    Middle Name:
Street Address:*
City:*    State:*   ZIP:
Telephone:*   Social Security:

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Position Applied For:   
How did you hear of this opening?
When can you start?     Desired Wage $

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Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis?
(You may be required to provide documentation.) Yes  No
Are you looking for full-time employment? Yes No
If no, what hours are you available?  
Are you willing to work swing shift? Yes No
Are you willing to work Weekends? Yes No
Have you ever been convicted of a felony? (This will not necessarily affect your application.) Yes No
If yes, please describe conditions.

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Education

School Name and Location	Year	Major	Degree
High School
College
College
Post-College
Other Training

In addition to your work history, are there other skills, qualifications, or experience that we should consider?

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Employment History (Start with most recent employer)
Company Name:
Address:     Phone:

Date Started:	Starting Wage:	Starting Position:
Date Ended:	Ending Wage:	Ending Position:

Name of Supervisor:
May we contact? Yes No
Responsibilities:
Reason for leaving:

Company Name:
Address:     Phone:

Date Started:	Starting Wage:	Starting Position:
Date Ended:	Ending Wage:	Ending Position:

Name of Supervisor:
May we contact? Yes No
Responsibilities:
Reason for leaving:

Company Name:
Address:     Phone:

Date Started:	Starting Wage:	Starting Position:
Date Ended:	Ending Wage:	Ending Position:

Name of Supervisor:
May we contact? Yes No
Responsibilities:
Reason for leaving:

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I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements on this application shall be considered sufficient cause for dismissal. This company is hereby authorized to make any investigations of my prior educational and employment history.

I understand that employment at this company is “at will,” which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager, or executive of this company, other than the president, has any authority to alter the foregoing.

Name:*        Date:*  
Email Address:*  

Spam Filter Question:* How many sides does a square have?