Employment Form

Employee Hire Date

Date

Personal information

First Name *

Last Name *

Date of Birth *

Social Security #

Phone *

Email *

(Present address) Street *

City *

State *

Zip *

(Permanent address) Street

City

State

Zip

Employment desired *

Full time

Part time

Temp

Seasonal

Position *

Date you can start *

Salary *

Are you employed now? *

Yes

No

If so may we inquire of your present employer?

Yes

No

Ever applied for this company before?

Yes

No

Where

When

Are you on layoff and subject to recall?

Yes

No

Will you travel if required?

Yes

No

Will you relocate if job requires it?

Yes

No

Will you work overtime if required?

Yes

No

Are you able to meet the attendance requirements of this position?

Yes

No

Have you ever been Bonded?

Yes

No

Have you ever been convicted of a felony in the past 7 yrs.

Yes

No

Such conviction may be relevant if job related, but does not bar you from employment. If yes – explain

Driver’s license number

State

Education

(Currently Attending) Name Of School

Location of School

Number of years Completed

Did you Graduate?

Yes

No

Subjects Studied

(Last Completed) Name Of School

Location of School

Number of years Completed

Did you Graduate?

Yes

No

Subjects Studied

(Currently Attending) Name Of School

Location of School

Number of years Completed

Did you Graduate?

Yes

No

Subjects Studied

(Last Completed) Name Of School

Location of School

Number of years Completed

Did you Graduate?

Yes

No

Subjects Studied

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work with this company.

Date Month and Year From

Date Month and Year To

Name of Employer

Address of Employer

Salary

Job

Reason for Leaving

Date Month and Year From

Date Month and Year To

Name of Employer

Address of Employer

Salary

Job

Reason for Leaving

Date Month and Year From

Date Month and Year To

Name of Employer

Address of Employer

Salary

Job

Reason for Leaving

References: Give the names of three persons not related to you to whom you have known at least 1 year

Name *

Address *

Phone *

Yrs. acquainted *

List any foreign language(s) and check the box that best describes your skill level

Language

Read and write

Read and speak

Speak only

Name *

Address *

Relationship *

Phone *

* Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or work sites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to physical examination, polygraph and/or substance testing. If required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal.

* It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.

* I give the employer the right to investigate all police, driving, and personal records and references, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

* The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

* Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation and failing settlement in mediation, to binding arbitration. Unless otherwise agreed a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company panel of mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.

* This application is current for 60 days. At the conclusion of this time if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.

Signature of Applicant *

Date *

Agency Management Notes

Academic

Trades of Business