Application for Employment Full Name (Last, First, MI) Social Security No. Current Address City State Zip Code Permanent Address City State Zip Code Phone No. 2nd Phone No. Referred By Email Address Employment Desired Employed Now? YesNo May we contact them? YesNo Legally Authorized to work in the U.S.? YesNo Ever applied to this company before? YesNo Where? When? Education History Name & Location of School Years Attended Did You Graduate? Subjects Studied High School / GED College Trade School, etc. Former Employers Date (Mo/Year) Name and Address of Employer Salary Position Reason for Leaving From To From To From To From To Eligibility Have you ever been convicted of a felony? Do you have any other specific skills to offer? References (Give below the names of three people not related to you who you have known for at least one year) Name Address Relation Years Known Authorization “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 specific period of time, or to make any agreement to the 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.” Date Signature Do Not Write Below This Line Date Interviewed By Remarks Neatness Character Personality Ability Hired Position Salary Approved Hiring Manager
