SAMPLE APPLICATION FOR EMPLOYMENT

[ Insert your company logo and address]

[Company] is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.

PERSONAL:

Name ________________________________________ Date __________
Last                         First                           Middle

Address _______________________________________________________
Number & Street            City                 State                 Zip Code

Position Sought ____________________   ___ Full Time ___ Part Time

Date Available ________    Salary Desired ________    Phone # _________

Email Address ________

Social Security Number ___________

Are you over 18 years old? __ Yes __ No

Are you legally eligible for employment in the United States?  __ Yes  __ No
(If offered employment, you will be required to provide documentation to verify eligibility.)

EDUCATION: Please indicate education or training which you believe qualifies you for the position you are seeking.

High School: No. of Yrs Completed (circle one) 1   2   3   4
Diploma: __ Yes __ No     G.E.D.: __ Yes __ No

School(s) ____________________ City/State ____________________

College and/or Vocational School:
Number of Years Completed (circle one) 1   2   3   4

School(s) ____________________ City/State ____________________

Major ____________________ Degrees Earned ____________________

Other Training or Degrees:

School(s) ____________________ City/State ____________________

Course _______________ Degree or Certificate Earned ______________

PROFESSIONAL LICENSE OR MEMBERSHIP:

Type of License(s) Held__________________________________________

State of [State Name]  License Number ___________________________________

License Expiration Date ___________________________________________

Other Professional Memberships ____________________________________

(You need not disclose membership in professional organizations that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry, age, disability, marital status, veteran status or any other protected status.)

This application for employment is good for 30 days only.

Consideration for employment after 30 days requires a new application.

SKILLS :
Office:    Typing _____ wpm.__ Microsoft Word       __ Excel    __ PowerpointOther Software Skills ___________________________________Have you ever been employed in any facility of [Company]?   __ Yes   __ NoIf so, please state facility name and location and dates of employment
______________________________RECORD OF CONVICTION : During the last ten years, have you ever been convicted of a crime other than minor traffic offense?
__ Yes __ NoIf yes, explain: _________________________________________________(A conviction will not necessarily automatically disqualify you for employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered).EMPLOYMENT: List last employer first, including U.S. Military Service.May we contact your present employer?    ____ Yes    ____ NoIf any employment was under a different name, indicate  name _____________Employer ____________________ Address _________________________Telephone _______________ Position _______________Dates of Employment: From _____ To _____
Mo/Yr     Mo/YrSalary __________ Supervisor ________________ Department __________

Duties _________________________________ FT __ PT __ No. of Hrs.___

Reason for Leaving ______________________________________________

Employer ____________________ Address _________________________

Telephone _______________ Position _______________

Dates of Employment: From _____ To _____
Mo/Yr     Mo/Yr

Salary __________ Supervisor _________________

Department __________

Duties _________________________________ FT __ PT __ No. of Hrs.___

Reason for Leaving ______________________________________________

Employer ____________________ Address _________________________

Telephone _______________ Position _______________

Dates of Employment: From _____ To _____
Mo/Yr     Mo/Yr

Salary __________ Supervisor _________________

Department __________

Duties _________________________________ FT __ PT __ No. of Hrs.___

Reason for Leaving ______________________________________________

Employer ____________________ Address _________________________

Telephone _______________ Position _______________

Dates of Employment: From _____ To _____
Mo/Yr     Mo/Yr

Salary __________ Supervisor _________________

Department __________

Duties _________________________________ FT __ PT __ No. of Hrs.___

Reason for Leaving ______________________________________________

If you wish to describe additional work experience, attach the above information for each position on a separate piece of paper.

Explain any gaps in work history: ___________________________________

Have you ever been discharged or asked to resign from a job? __Yes __No

If yes, explain: ________________________________________________

_____________________________________________________________

 REFERENCES:

APPLICANT’S CERTIFICATION AND AGREEMENT

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize [Company] to verify their accuracy and to obtain reference information on my work performance. I hereby release [Company] from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information.

I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.

I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the Employer. However, I further understand that neither the policies, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause.

Signature of Applicant ________________________ Date: __________