Part Time Service

Employment Application

PERSONAL – FILL IN THE BLANKS

Please indicate the location where you are interested in working: Name: Last First Middle Address Apt Number City State Zip Telephone Cell E-mail Address: Are you legally eligible for employment in the US?

YES NO

Are you 18 or older? YES NO

If no, please provide age Position applied for Date available to begin work: Do you have relatives who work for the company?

YES NO

If yes, please provide:

Name

Relationship

Location

Are you willing to work flexible hours including

weekends? YES NO

Do you plan to work at another job while in our employ?

YES NO

Are you interested in: Full Time Part Time

In case of emergency, person to notify (next of kin): Name:

Address:

City/State/Zip:

Phone Relationship

Hours available to work:

DAY MON TUE WED THU FRI SAT SUN

FROM:

TO:

Do you have a valid driver’s license? YES NO

State: Number: Exp:

Restrictions on license: Has your license ever been revoked or suspended?

YES NO

If yes, explain

Are you fluent in English? YES NO

Have you ever been bonded? YES NO

Have you ever been refused a bond? YES NO

If yes, explain: Have you ever been convicted of a crime? YES NO

(Criminal convictions will only be considered in relation to the job.) If yes, explain: Do you use or sell narcotics? YES NO

Are you willing to be tested for illegal drugs? YES NO EDUCATION REFERNCES – List three

Circle last year

completed

Graduated? Name of School Name: Length of time know: Yes No Location

Elementary Address: Telephone:

1 2 3 4

5 6 7 8 Comments:

High School

9 10 Name: Length of time know:

11 12

College Address: Telephone:

Comments:

Other (Including

professional

licenses)

Name: Length of time know:

Address: Telephone:

Comments:

EmploymentApplication20190218-NoFEIN.docx

MILITARY SERVICE

Have you ever served in the armed forces of the United States? YES NO Branch of Service: Date of Service: Rank or Rating at discharge: Honorable discharge? YES NO WORK EXPERIENCE

(List most recent first)

Start Employer and Address Supervisor, Title,

Phone

Ending

Salary

Reason for leaving

End

Position and Responsibilities

Start Employer and Address Supervisor, Title,

Phone

Ending

Salary

Reason for leaving

End

Position and Responsibilities

Start Employer and Address Supervisor, Title,

Phone

Ending

Salary

Reason for leaving

End

Position and Responsibilities

MEDICAL

If injured on the job, will you accept the medical facilities recommended by your employer? YES NO I authorize investigations of all statements contained in the application. I understand that any misrepresentation or omission of facts is cause for dismissal. I authorize my former schools, employers, and personal references to provide information from my records, including dates of attendance, degrees earned, dates of employment, salary earned, reason for leaving employment, and all other information they may have concerning my performance. I authorize investigation of my motor vehicle operating history and criminal background. I understand that an unsatisfactory report may result in denial or termination of employment. I also agree to observe and comply with company policies, rules and regulations and any violation may result in immediate termination. I release all parties providing information from any liability or claims for damages, including libel, slander, and invasion of privacy that may result from the disclosure of this information. Public Law 91-508 requires that we advise you that a routine inquiry may be made which will provide applicable information concerning character, general reputation, education, previous employment, and criminal background. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided. Applicant’s Signature: Date: It is our company policy not to discriminate against any employee or applicant for employment because of race, color, sex, age, disability, liability for service in the armed forces, or national origin. This policy includes but will not be limited to: EMPLOYMENT, DEMOTION, TRANSFER, RECRUITMENT, LAYOFF, TERMINATION, RATE OF PAY and SELECTION FOR TRAINING.

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