Full Name
Social Security No.
Present Address
City
State
Zip Code
Permanent Address
Phone No.
Email
Referred By
Position
Date you can start
Salary Desired
Are you employed?
YES NO
If so, may we inquire of your present employer? YES NO
Ever applied to this company before? YES NO
Where?
When?
Do you prefer part time or full time? Part time Full time
If part time, what days are you available:
Sun Mon Tue Wed Thu Fri Sat
Can you work weekend parties? YES NO
Name and Location of School
Years Attended
Did You Graduate?
Subjects Studied
Grammar School
High School
College
Trade, Business, or Correspondence School
Subjects of Special Study/Research, Work, or Special Training/Skills:
U.S. Military or Naval Service
Rank
(list below last four emp;loyers, starting with last one first)
Dates
Name and Address of Employer
Salary
Reason for Leaving
(Give below the names of three persons not related to you, whom you have known at least one year)
Name
Address
Business
Years Known
"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 that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any 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."
I have read and acknowledge the above statements:
Date:
