APPLICATION FOR EMPLOYMENT

An Equal Opportunity Employer

We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other
status protected by law or regulation. It is our intention that all qualified applicants be given equal opportunity
and that selection decisions be based on job-related factors.

Answer each question fully and accurately. No action can be taken on this application until you have answered all questions.
Use blank paper if you do not have enough room on this application. PLEASE PRINT, except for signature on back of
application. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal
preferences or discrimination based upon non-job-related information.

Job Applied for_____________________________________________________________ Today’s Date _________________________

Are you seeking: Full-time Part-time Temporary employment? When could you start work? ______________

_____________________________________________________________________________ _______________________
Last Name First Name Middle Name Telephone Number

________________________________________________________________________________________________________
Present Street Address City State Zip Code

Are you 18 years of age or older? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

(If you are hired, you may be required to submit proof of age.)

Social Security # __________________ If hired, can you furnish proof you are eligible to work in the U.S.? Yes No

Have you ever applied here before? Yes No If yes, when? __________________________________________
Were you ever employed here? Yes No If yes, when? __________________________________________
Have you ever been convicted of any law violation? Include any
plea of “guilty” or “no contest.” Exclude minor traffic violations.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

If yes, give details ___________________________________________________________________________________________

(A conviction will not necessarily disqualify an applicant for employment.)

If employed, do you expect to be engaged in any additional business

or employment outside of our job?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

If yes, give details ___________________________________________________________________________________________

For Driving Jobs Only: Do you have a valid driver’s license? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Driver’s License Number _______________________________ Class of License_______ State Licensed In ___________
Have you had your driver’s license suspended or revoked in the last 3 years? . . . . . . . . . . . . . . . Yes No
If yes, give details: ____________________________________________________________________________________
List professional, trade, business or civic activities and offices held. (Exclude labor organizations and memberships which reveal
race, color, religion, national origin, sex, age, disability or other protected status.) ____________________________________
_____________________________________________________________________________________________________

Number of Diploma/
Subjects
LIST NAME AND ADDRESS OF SCHOOLS Years Degree/
Studied
Completed Certificate
High School or GED: _________________________________________________________________________________________________
College or University: ________________________________________________________________________________________________
Vocational or Technical: _____________________________________________________________________________________________
What skills or additional training do you have that relate to the job for which you are applying? ____________________________
____________________________________________________________________________________________________________________
What machines or equipment can you operate that relate to the job for which you are applying?____________________________
____________________________________________________________________________________________________________________

MSEC 1.1a (09/02)

 List names of employers in consecutive order with present or last employer listed first. Account for all periods of time
including military service and any periods of unemployment. if self-employed, give firm name and supply business
references. Note: A job offer may be contingent upon acceptable references from current and former employers.
NAME OF EMPLOYER JOB TITLE AND DUTIES

ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM TO

CITY, STATE, ZIP CODE

PAY: START $ FINAL $

SUPERVISOR(S) TELEPHONE Reason For Leaving

NAME OF EMPLOYER JOB TITLE AND DUTIES

ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM TO

CITY, STATE, ZIP CODE

PAY: START $ FINAL $

SUPERVISOR(S) TELEPHONE REASON FOR LEAVING

NAME OF EMPLOYER JOB TITLE AND DUTIES

ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM TO

CITY, STATE, ZIP CODE

PAY: START $ FINAL $

SUPERVISOR(S) TELEPHONE REASON FOR LEAVING

NAME OF EMPLOYER JOB TITLE AND DUTIES

ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM TO

CITY, STATE, ZIP CODE

PAY: START $ FINAL $

SUPERVISOR(S) TELEPHONE REASON FOR LEAVING

Have you worked or attended school under any other names? . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
If yes, give names: _________________________________________________________________________________________
Are you presently employed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
If yes, whom do you suggest we contact? ____________________________________________________________________
Have you ever been fired from a job or asked to resign? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
If yes, please explain: _______________________________________________________________________________________
Give three references, not relatives or former employers.
Name Address Phone
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further
consideration for employment and may result in my dismissal if discovered at a later date.
I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers
and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in
making such statements.
I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of
employment, if required.
I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to
the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.
I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED
CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZATION HAS THE AUTHORITY
TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE PRESIDENT AND THE
EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH
OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.
I have read, understand, and by my signature consent to these statements.

Signature: ________________________________________________________________________________________________________________ Date: _________________________________

This application for employment will remain active for a limited time. Ask the organization’s representative for details.
 APPLICANT AFFIRMATIVE ACTION INFORMATION

It is the policy of this organization to provide equal employment opportunity to all qualified applicants
for employment without regard to race, color, religion, national origin, sex, age, veteran status or
disability.

COMPLETION OF THIS FORM IS VOLUNTARY AND IN NO WAY AFFECTS THE DECISION

REGARDING YOUR APPLICATION FOR EMPLOYMENT. THIS FORM IS CONFIDENTIAL AND
WILL BE MAINTAINED SEPARATELY FROM YOUR APPLICATION FORM.

PLEASE PRINT

Name ______________________________________________________ Date ________

Last First Middle

Position applied for (list only one) ___________________________________________________

Where did you hear about this job? ________________________________________________

Racial origin (You may mark one or more of the following):

 White—A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
 American Indian or Alaska Native—A person having origins in any of the original peoples of North and South America
(including Central America), and who maintains tribal affiliation or community attachment.
 Black or African American—A person having origins in any of the black racial groups of Africa.
 Asian—A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent
including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and
Vietnam.
 Native Hawaiian or Other Pacific Islander—A person having origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.

Ethnicity:
 Hispanic or Latino—A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or
origin, regardless of race.

Sex:  Male  Female

 I elect not to identify

Signature ___________________________________________________________

MSEC 1.2 (07/07)