employment application

Position Applying For:

Personal Information

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip Code:

Telephone:

E-Mail:

Have you ever been convicted of a felony?:

   yes

   no

If yes, please explain::

Employment History

Employer:

Address:

City:

State:

Zip Code:

Your Position:

Salary:

Duties:

Dates of Employment:

Reasons for Leaving:

May we contact your supervisor?:

   yes

   no

Prior Employer:

Address:

City:

State:

Your Position:

Salary:

Duties:

Dates of Employment:

Reasons for Leaving:

May we contact your supervisor?:

   yes

   no

Education

High School:

Address:

City:

State:

Zip Code:

Did you graduate?:

   yes

   no

If no - what was last grade completed?:

Special honors or awards:

Did you attend technical or vocational school:

   yes

   no

Name of School:

Degree of Certification:

Specialty:

Special honors or awards:

How did you hear about this job?:

What hours are you willing to work?:

Would you be able to work weekends?:

   yes

   no

Are you willing to travel for the job?:

   yes

   no

When would you be able to start?:

Desired Salary:

Date:

I hereby certify that my answers and assertions set forth in this application are true and complete to the best of my knowledge. If I am employed, I understand that any false statements on this application shall be considered sufficient cause for my dismissal. I hereby authorize this company to investigate any aspect of my prior educational and employment history.

Furthermore I understand that if I am hired, employment with this company is "at will," which means that either the company or I can terminate my employment for any reason not prohibited by state or federal law.