Job Application

(Company Name Here) is an equal opportunity employer. This application will not be used for
limiting or excluding any applicant from consideration for employment on a basis prohibited by
local, state, or federal law. Should an applicant need reasonable accommodation in the
application process, he or she should contact a company representative.

Please fill out all of the sections below:

Name ____________________________________________ Date _________________

Home Address _______________________________________________________________

City, State, ZIP _______________________________________________________________

Home Telephone # ___________________________ Cell # _______________________

Email Address _______________________________________________________________

Employment Position

Position applying for: ________________________ (Circle one) Full time Part time

What day(s) are you available to work: Mon. Tues. Wed. Thurs. Fri. Sat.

When can you start working if hired? ______________________________________________

Do you have reliable transportation to and from work? Yes No

Salary desired: ________ /hour

Personal Information

Have you ever applied to or worked for (Company Name Here) before? Yes No

Do you have any friends or relatives working for (Company Name Here)? Yes No
If yes, state name & relationship: _________________________________________________

Are you 18 years of age or older? Yes No

Can you provide proof of citizenship or legal status? Yes No

Do you have any conditions which would require job accommodations? Yes No
If yes, please describe accommodations required: ____________________________________

___________________________________________________________________________

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Applicant Name _________________________________

Have you ever been convicted of a criminal offense (felony or misdemeanor)? Yes No
If yes, please state the nature of the crime(s), when & where convicted and disposition of the case:

__________________________________________________________________________

___________________________________________________________________________

(Note: No applicant will be denied employment solely on the grounds of a criminal offense. The date of the
offense, the nature of the offense, including any significant details that affect the description of the event,
and the surrounding circumstances and the relevance of the offense to the position(s) applied for may,
however, be considered.)

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position in which you are
applying.

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

(Note: (Company Name Here) complies with the ADA and considers reasonable accommodation measures
that may be necessary for eligible applicants/employees to perform essential functions.)

Education and Training

High School
Name Location (City, State) Year Graduated Degree Earned

College/University
Name Location (City, State) Year Graduated Degree Earned

Vocational School/Specialized Training

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Applicant Name _________________________________

Previous Employment

(1) Employer Name __________________________________ Job Title ______________

Supervisor Name _____________________________________________________________

Address ____________________________________________________________________

City, State, ZIP _______________________________________________________________

Phone # ___________________________ Dates Employed _________________________

Reason for leaving ____________________________________________________________

(2) Employer Name __________________________________ Job Title ______________

Supervisor Name _____________________________________________________________

Address ____________________________________________________________________

City, State, ZIP _______________________________________________________________

Phone # ___________________________ Dates Employed _________________________

Reason for leaving ____________________________________________________________

References

(1) Name ____________________________________ Phone # ____________________

(2) Name ____________________________________ Phone # ____________________

At-Will Employment

The relationship between you and (Company Name Here) is referred to as “employment at will.” This
means that your employment can be terminated at any time for any reason, with or without cause, with or
without notice, by you or (Company Name Here). No representative of (Company Name Here) has authority
to enter into any agreement contrary to the foregoing “employment at will” relationship. You understand
that your employment is “at will,” and that you acknowledge that no oral or written statements regarding
your employment can alter your at-will employment status, except for a written statement signed by you
and either of the Company’s owners.

Employee Signature ____________________________________ Date ______________

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