Associate Degree United States

Application for Employment

This form must be completed in full. You may attach a resume, but you may not write “see resume” in lieu of completing any part of this form.

PERSONAL INFORMATION DATE:

Name:

Address:

City, State, Zip:

Home Phone Number Cell Phone Number E-mail Address POSITION INFORMATION

Indicate the position you are applying for:

Desired employment: Full Time Part Time Temporary Contingent Date available to work: Salary requirement:

Can you perform the essential duties of the job in which you wish to be employed, with or without accommodation? No Yes If with accommodation, please describe accommodation requested: Highest level of education completed: High School Associate Degree Bachelor Degree Post-Grad Degree Please list any skills/certifications/licenses you have related to this position: How did you hear about this position?

GENERAL INFORMATION

Have you ever been convicted of a crime? No Yes (An affirmative answer will not automatically disqualify you from being considered as a candidate for employment.)

If yes, please explain:

Are you legally authorized to work in the United States? No Yes Are you below the age of 18? No Yes

Have you ever applied to/worked here before? No Yes If yes, please explain (include date): Do you have any friends/relatives/acquaintances working here? No Yes If yes, state name and relationship: REFERENCES

Please list references that are not related to you by blood, adoption or marriage. Name and Address Occupation Telephone Number

1

2

3

EMPLOYMENT HISTORY

Are you currently employed? No Yes If yes, may we inquire of your present employer? No Yes Name of current or most recent employer:

Address:

Telephone Number: Fax Number:

Employed from: to

Supervisor’s Name:

Job Title/Duties:

Reason for Leaving:

Name of previous employer:

Address:

Telephone Number: Fax Number:

Employed from: to

Supervisor’s Name:

Job Title/Duties:

Reason for Leaving:

Name of previous employer:

Address:

Telephone Number: Fax Number:

Employed from: to

Supervisor’s Name:

Job Title/Duties:

Reason for Leaving:

I understand that nothing in this application is intended to imply or create an employment relationship or contract for employment. I further understand that if hired, my employment is at-will and can be terminated at any time, with or without notice, for any reason, or for no reason at all. I also understand that while personnel policies, programs and procedures may change from time to time, such at-will status is not subject to change absent a written agreement signed by the President or a designated authorized representative. I acknowledge that the information I have supplied is correct to the best of my knowledge and understand that any deliberate falsification, misrepresentation or omission of fact may be grounds for rejection of my application or dismissal from subsequent employment. I authorize the Company to verify the accuracy of the above statements and to obtain reference information on my work performance. I hereby release the 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. Company is an equal opportunity employer. SIGNATURE: DATE:

THIS FORM HAS BEEN DESIGNED TO COMPLY WITH STATE AND FEDERAL FAIR EMPLOYMENT LAWS PROHIBITING DISCRIMINATION ON THE BASIS OF AN APPLICANT'S SEX OR MINORITY STATUS. QUESTIONS DIRECTLY OR INDIRECTLY REFLECTING SUCH STATUS HAVE BEEN INCLUDED ONLY WHERE NEEDED TO DETERMINE A BONAFIDE OCCUPATIONAL QUALIFICATION OR FOR OTHER PERMISSIBLE PURPOSES. Revised 08/2018 - CFR

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