Application for Employment
Equal Opportunity Employer
Name:
Social Security:
Date:
Address:
City:
State:
Zip:
Telephone:
Referred By:
Employment Desired
Position:
Start Date:
Salary Desired:
Are you
employed now
?
May we inquire with
your present employer?
Are you legally authorized
to work in the US?
YES
NO
YES
NO
YES
NO
Education History
High School:
Year Graduated:
City & State:
College:
Year Graduated:
City & State:
Trade School:
Year Graduated:
City & State:
General Information
Subjects of Special Study:
Special Training:
Special Skills:
Military Service:
Former Employers (List below last four employers, starting with last one first)
Reason for
Leaving:
Start Date:
Employer:
Salary:
End Date:
Address:
Position:
_________________________________________________________________________________________________________
Start Date:
Reason for
Leaving:
Employer:
Salary:
End Date:
Address:
Position:
_________________________________________________________________________________________________________
Reason for
Leaving:
Start Date:
Employer:
Salary:
End Date:
Address:
Position:
_________________________________________________________________________________________________________
Start Date:
Reason for
Leaving:
Employer:
Salary:
End Date:
Address:
Position:
References:  (Give below the names of three individuals not related to you, whom you have known at least one year)
1. Name & Contact Information:
2. Name & Contact Information:
3. Name & Contact Information:
AUTHORIZATION
"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 all liability for any damage that may result from
utilization of such information.

I also understand and agree to no representative of the company has any  authority to enter into any
agreement for employment for any specified period of time, or to make an 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."
X - Sign by Inserting Name:
Date:
Questions, comments, or additional information:
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