Application For Employment

APPLICATION FOR EMPLOYMENT

Applying Job Option:

fill out the application submit with resume

Position Applying for: Application For Employment

Date: 5-18-2025

PERSONAL INFORMATION

Name (Last, First):

Street Address:

City:

State:

Zip code:

Phone:

Email:

Have you ever worked or attended school under any other names?
Yes No

ELIGIBILITY

YOUR EDUCATION AND TRAINING

Educational Level	Name of Institution	From	To	Did you graduate?	Degree / Major Course of Study
High School/GED
Graduate School
College/University
Trade/Technical School
Other

YOUR WORK EXPERIENCE (LIST UP TO 4 EXPERIENCE, STARTING WITH THE MOST RECENT OR CURRENT)

Name of Employer:

Starting Position:

Street Address:

Ending Position:

City:

State:

Zip code:

Start Date:

End Date:

Name and title of immediate supervisor:

Current employer?
Yes No

May we contact this employer?
Yes No

Phone:

Reason for leaving:

Add Employer

ADDITIONAL QUESTIONS

Are you authorized to work in the US for any employer? You will be required to provide proof of employment eligibility upon hire.

Yes No

Are you 18 years of age or older?

Yes No

May we contact your present employer?

Yes No

Do you have a reliable means of transportation?

Yes No

Are you able to work overtime if necessary?

Yes No

Are there any hours, shifts, days you will not work? If yes, please list:

Yes No

If selected for employment, are you willing to submit to a pre-employment drug screening test?

Yes No

Are you able to perform the essential functions of the job with or without reasonable accommodation?

Yes No

Have you ever been fired from a job or asked to resign? If yes, please explain:

Yes No

YOUR MILITARY EXPERIENCE

Completing this section of the application is optional. Leave this area blank if you do not wish to answer.

Have you ever served in the United States Armed Services?
Yes No

YOUR REFERENCES

Name:

Occupation:

Address:

City/State:

Phone:

Relationship to Applicant:

Add Reference

APPLICANT STATEMENT

PLEASE READ THE FOLLOWING PARAGRAPHS CAREFULLY:

By signing below, I certify that I have read, understand and agree to each of the following statements:

All of the information I have supplied on this application is true, accurate and complete, to the best of my knowledge, and I have not knowingly withheld any information which, if known to the Company, would affect my application unfavorably.

If I am hired by the Company, and if the Company discovers at any time during my employment that any of the statements or answers on this application are false, misleading, or incomplete, I may be dismissed immediately from my job.

This employment application will be considered active for ninety (90) days from the date received by the Company. If I want to be considered for a job with the Company after this period of time I must fill out another application.

I agree to submit to a medical examination, which may include testing for drugs or alcohol prior to beginning work with the Company.

I understand that if the Company employs me, I may be required, when job related and/or consistent with the Company's business needs or practice, to undergo a medical examination or testing for alcohol. I further understand that I may be required to submit to a test for the use of illegal drugs at any time. I consent to the disclosure of test results and other Protected Health Information to the designated company representative(s) or its Business Associates.

In consideration of my employment with the Company, I agree to abide by all the Company's rules and regulations.

I understand that nothing in this employment application creates a contract of employment between the Company and me. If I am hired by the Company, my employment and compensation are "at will," which means that my employment can be terminated, either by the Company or me, with or without cause, and with or without notice. I understand that no manager or supervisor has the authority to make any employment agreement with me, either orally or in writing, that is not an at-will agreement. Only the President of the Company has the authority to enter into an employment agreement with me for any specified period of time.

I agree to release to the Company or its business associates all medical information, including but not limited to files, reports, x-rays, evaluations, and opinions held by medical personnel, to the extent such information is job-related and consistent with the Health Insurance Portability and Accountability Act and the Company's business needs. I acknowledge that this is a general release and that if hired, it remains in effect for the duration of my employment.

In the event of my personal indebtedness to the Company, I authorize the Company to withhold from my wages such amounts as permitted by law to satisfy my obligation to the Company.

I give the Company my permission to conduct any investigation regarding the information contained in my employment application, which the Company thinks is necessary to determine my qualifications for assuming a job with the Company. I give the Company my permission to contact any former employer, school, college or university, utility company, credit or finance bureau or office, any personal or professional reference, or any other appropriate source or individual for the purpose of gathering any information, personal or otherwise, that such sources may have about my character, general reputation, credit, education, or employment record, and I give my consent to any such source to release to the Company whatever information they have about me. I also unconditionally release all named and unnamed sources from any and all liability, which might result from furnishing any information about me.

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