AppIication for EmpIoyment

(Company)

SAMPLE APPLICATION FOR EMPLOYMENT

We consider qualiIied applicants Ior all positions without regard to race, color, religion,
sex, national origin, age, veteran status, handicap, or any other legally protected status.

PLEASE PRINT

Date

A. PERSONAL INFORMATION

Name Social Security No.

Street Address

City State Zip Code

Business Telephone: Home Telephone:

Are you 18 years oI age or older? Yes No

Are you prevented Irom becoming lawIully employed because oI visa or immigration
status? Yes No

Have you ever been convicted oI a crime, other than a minor
traIIic oIIense? II so, please explain.

NOTE: A prior conviction will not necessarily bar you Irom employment; however, the
type oI conviction and when it occurred will be considered.

In case oI emergency contact:

Name

Address Phone Number


B. EMPLOYMENT DESIRED

Position: Date you can start:

Salary Desired:

Are you able to perIorm the essential Iunctions oI the position Ior which you have
applied, with or without reasonable accomodation? Yes No

Have you applied to this company beIore?

Where?

When?

Have you been previously employed by this company?

Where?

When?

Reason Ior leaving

Who reIerred you to this company?

C. EDUCATION

Name and
Location
No. oI Years
Attended
Subjects
Studied
Did You
Graduate?
High School
College
Other


C. MILITARY EXPERIENCE

Were you in the military service? Yes No

II yes, what branch and rank at separation?

BrieIly describe your duties

D. EMPLOYMENT HISTORY

State the Iollowing: (identiIy your last Iive employers, starting with the latest one).
Date/Month and
Year
Name / Address oI
Employer
Name / Address oI
Supervisor
Position
Reason Ior
Leaving
From:

To:

From:

To:

From:

To:

From:

To:




E. REFERENCES (give the names oI three persons you have known at least one year and
who are not related to you.)
Name Address usiness Years Acquainted
1.
2.
3.


CERTIFICATE OF APPLICANT (READ CAREFULLY BEFORE SIGNING)

I certiIy that the inIormation in this application (and accompanying resume or
inIormation) is true. I also agree and understand that misrepresentations or Ialse or
omitted Iacts may disqualiIy me Irom Iurther consideration Ior employment and may be
considered justiIication Ior my termination iI discovered at a later date.

I authorize investigation oI the statements contained herein and the reIerences listed
above to give you any and all inIormation such persons, schools, and employers or
organizations may have, and release all parties Irom all liability Ior any damage that may
result Irom Iurnishing this inIormation to you. I authorize you to request and receive any
and all inIormation Irom my entire work and personal history.

I understand that, iI hired, my employment is Ior no deIinite period and may be
terminated at any time, with or without cause, at the discretion oI either the company or
myselI. I understand that I will remain an at will employee and can be terminated at any
time without any notice, absent a written contract signed by the President oI the
Company and myselI. II I am employed, it is also understood that the Company, at its
sole option and without prior notice, can change wages, beneIits, rules, regulations and
the conditions oI my employment at any time.

I acknowledge that I may be oIIered employment subject to a medical examination and/or
questionnaire, and that such examination and/or questionnaire could nulliIy my ultimate
employment by this employer. I agree to submit to any such medical examination and/or
questionnaire.

Signature oI Applicant
Date