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Employee Application


Personal Information




Contact Information



Date of Application:
24 September 2023

Work Eligbility

Date Available for work:
What is your desired salary range:
Can you perform the essential duties of the job in which you wish to be employed, with or without reasonable accommodation?
Are you able to meet the attendance requirements of the position?


Answering "YES" to these questions does not constitute and automatic bar to employment. Factors such as date of the offense, seriousness of the violation, rehabilitation and position applied for will be taken into account.
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?
If yes, please provide date(s) and details.

Drivers License

License State:

Employment History

List last employer first, including US military service.

First Previous Job:

Previous Employer
Previous Supervisor
Hourly Rate / Salary:

Second Previous Job:

Previous Employer
Previous Supervisor
Hourly Rate / Salary:

Third Previous Job

Previous Employer
Previous Supervisor
Hourly Rate / Salary:

Skills and Qualifications

Summarize any training, skills, licenses, and / or certificates that may qualify tou as being able to perform job-related functions in the position for which you are applying:

Educational Background:

Name and Location Number of Years Completed Did you Graduate? Course of Study
High School      
College Major: Degree:


Name Telephone Years Known

Application Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete, and correct.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer’s service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

If I am hired, I understand that I am an "at will" employee where as I am free to resign at any time, with or without causes and without prior notice and the employer resaves the same right to terminate my employment at any time, with or without cause and without prior notice, unless otherwise required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurance to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and federal immigration laws require me to complete an I-9 Form inthis regard.


I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

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