APPLICATION FOR EMPLOYMENT
[Company name]  

An Equal Opportunity Employer.
Reasonable accommodation will be provided as required by law.

Last Name                             First Name                         Middle Initial | Social Security Number:
Street Address                      City/State                          Zip Code | Phone Number:
If hired, can you provide evidence of legal eligibility to work in the U.S.? | Any offer of employment is conditioned upon completing form I-9 and providing the appropriate documents for identity and work authorization.

Position Desired:

Wage/Salary Desired:

Full Time?
Part Time?

Date you can begin work? | Are you 18 years of age or older? | If under 18 years of age, you will be required to submit a birth certificate or work certificate as required by state or federal law.
Name of high school attended: | City & State | Graduate? | GED? |
Name of college or technical school: | City & State | Graduate? | Degree? | Major:
Are you presently enrolled in school? | If yes, give name & address of school and expected degree date:
List any job-related skills or accomplishments, including military service:
- Your Availability For Work -
| Monday | Tuesday | Wednesday | Thursday | Friday | Saturday | Sunday
From: | | | | | | |
To: | | | | | | |
Total hours per week you are available to work: | Do you have any special requests or needs for a work schedule?
- Provide Three References Who Are Not Former Employers Who We May Contact -
Name and Occupation | How do you know them, and for how long? | Phone Number

Your Employment History

List names of employers with present or last employer listed first.

May we contact current employers before you are offered a position? _____

Name of Employer:

Job Title:
Duties:

Address:

Dates of Employment: 
From:                                       To:

City, State, Zip Code

Hourly pay or salary: 
Starting pay:                             Ending pay:

Supervisor:  

Telephone:

Reason for Leaving:

Name of Employer:

Job Title:
Duties:

Address:

Dates of Employment: 
From:                                       To:

City, State, Zip Code

Hourly pay or salary: 
Starting pay:                             Ending pay:

Supervisor:  

Telephone:

Reason for Leaving:

Name of Employer:

Job Title:
Duties:

Address:

Dates of Employment: 
From:                                       To:

City, State, Zip Code

Hourly pay or salary: 
Starting pay:                             Ending pay:

Supervisor:  

Telephone:

Reason for Leaving:

CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM

I certify that all of the information provided in this employment application is true and complete to the best of my knowledge, and I authorize investigation of all statements contained in this application, including a criminal background, credit history check, and drug test, as applicable.  I understand that any false or incomplete information may disqualify me from further consideration for employment and may result in my immediate discharge if discovered at a later date.

I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer, past employers, and other organizations to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision.  I release such persons and organizations from any legal liability in making such statements.

I have read, understand, and agree to the above statements.

Signature: | Date: