Position Applied For
Position Name
Personal Information
Name
Phone Number
Alternate Phone Number
Present Address
City
State
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
How long have you lived there?
Email Address
Desired Salary / Hourly Rate
If under the age of 18, can you produce the necessary work certificate at the time of employment?
Type of employment desired?
N/A
Full-time
Part-time
Specify Hours
Specified Hours
Are you willing to work overtime?
Date on which you can start work if hired
Have you previously applied for employment with this Company?
If Yes, when and where did you apply?
Have you ever been employed by this Company?
If Yes, provide dates of employment, location and reason for separation from employment.
List any other names by which you have been known
If applicable, list any other names which may be necessary to allow us to confirm your work and educational record. For example, change of name, use of an assumed name, nickname, etc.
High School
School Name and Location
Course of Study or Major
Number of years completed
Honors Received
College
School Name and Location
Course of Study or Major
Number of years completed
Honors Received
Graduate School
School Name and Location
Course of Study or Major
Number of years completed
Honors Received
Trade or Correspondence
School Name and Location
Course of Study or Major
Number of years completed
Honors Received
Employment History
List present or most recent employer first.
Employer 1
Employer
Address
Type of Business
Phone
Dates Employed
Start Date
End Date
Job Title
Duties
Supervisor's Name
If No, why not?
Wages Start
Wages Final
Reason for Leaving
What will this employer say was the reason your employment terminated?
Were you ever disciplined? If so, for what?
How much notice did you give when resigning? If none, explain.
Employer 2
Employer
Address
Type of Business
Phone
Dates Employed
Start Date
End Date
Job Title
Duties
Supervisor's Name
If No, why not?
Wages Start
Wages Final
Reason for Leaving
What will this employer say was the reason your employment terminated?
Were you ever disciplined? If so, for what?
How much notice did you give when resigning? If none, explain.
Have you ever been terminated or asked to resign from any job?
If Yes how many times?
Has your employment ever been terminated by mutual agreement?
If Yes how many times?
Have you ever been given the choice to resign rather than be terminated?
If Yes how many times?
If you answered Yes to any of the above three questions, please explain the circumstances of each occasion.
Work Reference 1
Name
Position
Company
Work Relationship
Phone
Work Reference 2
Name
Position
Company
Work Relationship
Phone
Personal Reference 1
Name
Occupation
Phone
Number of Years Known
Address
Personal Reference 2
Name
Occupation
Phone
Number of Years Known
Address
Driving Information
(Complete only if driving is an essential function of the job for which you are applying).
Do you have a current valid driver’s license?
If yes, License No.
License State
License Expiration Date
Date
Time
If you do not have a driver’s license for the state in which you currently reside, why not?
Has your license ever been suspended or revoked?
If yes, explain
Do you have personal automobile insurance?
If no, explain
Have you ever been denied personal automobile insurance or has it ever been terminated or suspended?
If yes, explain
Moving Offenses
Please list all moving traffic violations in the last five (5) years
Offence 1
Offense
Date
Location
Comments
Offence 2
Offense
Date
Location
Comments
I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver's license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside.
I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that all employees of the location, pursuant to the Company's policy and federal, state, and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs.If employed, I understand that the taking of alcohol and/or drug tests is a condition of continual employment and I agree to undergo alcohol and drug testing consistent with the Company's policies and applicable federal, state, and local law.
If employed by the Company, I understand and agree that the Company, to the extent permitted by federal, state, and local law, may exercise its right, without prior warning or notice, to conduct investigations of property (including, but not limited to, files, lockers, desks, vehicles, and computers) and, in certain circumstances, my personal property.
I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement.
I certify that all the information on this application, my résumé, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.
THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT—EXPRESS OR IMPLIED—WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY.IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL.
I authorize the Company or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I am seeking to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation which may be permitted by federal, state and/or local law. If applicable and allowed by law, I will receive separate written notification regarding the Company's intent to obtain "consumer reports."
I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information. Further, if hired, I authorize the company to provide truthful information concerning my employment to future employers and hold the company harmless for providing such information.
If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Company. I also understand this Company employs only individuals who are legally eligible to work in the United States.
THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.
I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE.
DO NOT SIGN UNTIL YOU HAVE READ ALL OF THE INFORMATION CONTAINED IN THE APPLICATION.
Electronic Signature
I certify that all statements I have made on this application are true and complete to the best of my knowledge. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that any omission or misrepresentation of fact may result in refusal of employment or immediate dismissal. I authorize the investigation of all statements that I have made in this application. I hereby acknowledge that I have read and understand the above statements.
Date
If the applicant is a minor, the foregoing release and consent must be signed by the applicant's parent or legal guardian. Signature by the applicant's parent or legal guardian constitutes acknowledgement by the applicant and the parent or legal guardian that the Company, to the extent permitted by federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate test results to Company personnel who need to know, the applicant, and the applicant's legal guardian.
Parent/Guardian Signature
Date
UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR, POLYGRAPH, OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.
I have read and understand the above statement.
Electronic Signature
Date
IT IS UNLAWFUL IN MASSACHUSETTS TO REQUIRE OR ADMINISTER A LIE DETECTOR TEST AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITY.
FOR CALIFORNIA APPLICANTS ONLY: BY CHECKING THIS BOX, I WAIVE MY RIGHT TO RECEIVE A COPY OF ANY PUBLIC RECORD OBTAINED BY THE COMPANY FOR EMPLOYMENT PURPOSES THROUGH AN INTERNAL INVESTIGATION. FEDERAL AND/OR STATE LAW MAY PROHIBIT THE USE OF LIE DETECTOR, POLYGRAPH OR SIMILAR TEST AS WELL. THIS APPLICATION MAY NOT BE SUFFICIENT FOR ALL INDUSTRIES OR APPROPRIATE FOR USE IN ALL LOCALITIES.
THIS APPLICATION MAY NOT BE SUFFICIENT FOR ALL INDUSTRIES OR APPROPRIATE FOR USE IN ALL LOCALITIES.
Submit