Employment Application

Employees/Board Access | Customer Account Access

Application For Employment

* denotes a required field

First Name *

Middle Initial

Last Name *

Present Address *

City *

State *

Zip Code *

Telephone Number *

Alternate Telephone Number

() -

Email Address

Position for which you are applying *

I am available to work:

Full Time Part Time

Have you previously filed an application with this company?

Preference

YesNo

Full TimePart Time

Do you have any relatives employed by this company?

Relationship

YesNo

Have you previously been employed by this company?

YesNo

Who referred you to us? (please check the appropriate option)

A-Newspaper	B-Employee Referral Name:	C-Employment Agency
D-Walk In	E-Other:

BEGINNING WITH YOUR MOST RECENT EMPLOYMENT, please give a complete record of your employment history.

Employers Name *

Start Date

Starting Salary/Wage *

Termination Date

Last Salary/Wage *

Address *

Job Title *

Employer Telephone Number *

() -

Briefly list your primary responsibilities.

1. *		2.
3.		4.

Employers Name *
Not Applicable

Start Date

Starting Salary/Wage *

Termination Date

Last Salary/Wage *

Address *

Job Title *

Employer Telephone Number *

() -

Briefly list your primary responsibilities.

1. *		2.
3.		4.

Employers Name *
Not Applicable

Start Date

Starting Salary/Wage *

Termination Date

Last Salary/Wage *

Address *

Job Title *

Employer Telephone Number *

() -

Briefly list your primary responsibilities.

1. *		2.
3.		4.

REFERENCES: Give the names of three individuals not related to you whom you have known at least one year.

Name *	Address *	Business *	Email Address *	Telephone Number *
				() -
				() -
				() -

EDUCATION SUMMARY
High School *	City/State *	Dates Attended	Did you graduate? *
		To	YesNo
College or Technical	Type of Degree/Major/Certificate	Dates Attended	Did you graduate?
		To	YesNo
Business College	Area (Coursework)	Dates Attended	Did you graduate?
		To	YesNo
Other Schooling	Type of Study	Dates Attended	Certificate or Diploma
		To

List any licenses, achievements, awards, activities, or accomplishments which you feel might especially help to qualify you for employment.

*This company does not discriminate in employment practice on the basis of Race, Sex, Marital or Veteran Status, Physical Handicap, Religion, National Origin, nor on the basis of Age.

APPLICANT: Be sure to read the following statement before submitting.

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time.
In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.