EMPLOYMENT APPLICATION DATE ___________
You must be at least 16 years of age or older.
You must be willing to work nights, weekends and holidays.
Dress code: Black slacks, black shoes (no open toed shoes), white shirt with collar.
YOUR NAME ___________________________________ TELEPHONE NUMBER ____________________________
ADDRESS ___________________________________ I AM SEEKING TEMPORARY WORK UNTIL ____________
_____________________________________________ I AM SEEKING A PERMANENT POSITION? YES OR NO
SOCIAL SECURITY # __________________________ I AM WILLING TO WORK ALL HOLIDAYS? YES OR NO
DO YOU HAVE ANY PHYSICAL CONDITIONS WHICH MAY LIMIT THE PERFORMANCE OF DUTIES IN THE
POSITION FOR WHICH YOU HAVE APPLIED? IF YES, PLEASE EXPLAIN ______________________________________
_________________________________________________________________________________________________________
IF NECESSARY FOR THE JOB CAN YOU: WORK SHIFTS? _________________________
WORK OVERTIME? _________________________ TRAVEL? ______________________________
IF NECESSARY FOR THE JOB, ARE YOU AT LEAST 15 16 17 18 19 21 (PLEASE CIRCLE)
I WILL BE ABLE TO REPORT FOR WORK ____ DAYS AFTER BEING NOTIFIED THAT I AM HIRED.
ARE THERE ANY DAYS OF THE WEEK YOU ARE NOT ABLE TO REPORT TO WORK? ____________________________
EDUCATION SCHOOL NAME/ADDRESS GRADUATED MAJOR SUBJECT GPA
High School
____________________________________________________________________________________________________________
College/University
____________________________________________________________________________________________________________
Other
____________________________________________________________________________________________________________
REFERENCES: List two personal references who are not relatives or former supervisors.
Name Address Occupation Years Known
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
EMPLOYMENT: List last employment first. Include summer or temporary jobs.
Please show dates and locations of self-employment or periods of unemployment.
DATES EMPLOYER NAME/ADDRESS POSITION / DUTIES / SKILLS REASON FOR LEAVING
from
to________
Salary
start
end Supervisor
__________________________________________________________________________________________________________
from
to________
Salary
start
end Supervisor
__________________________________________________________________________________________________________
from
to________
Salary
start
end Supervisor
__________________________________________________________________________________________________________
OTHER INFORMATION:
Subjects of special study or research work:________________________________________________________________________
__________________________________________________________________________________________________________
Special Training: ___________________________________________________________________________________________
__________________________________________________________________________________________________________
Activities: (Civic, Athletic, Etc.): ______________________________________________________________________________
__________________________________________________________________________________________________________
Contact (in case of accident or illness) Name_____________________________________________________________________
Address___________________________________________________________Daytime Phone____________________________
Information to the applicant: As part of our procedure for processing your employment application, your personal
and employment references may be checked. If you have misrepresented or omitted any facts on this application, and
are subsequently hired, you may be discharged from your job. You may make a written request for information derived
from the checking of your references.
If necessary for employment in a specific position, you may be required to : have a physical examination, to provide evidence of citizenship or
date of birth, or to sign a conflict of interest agreement and abide by its terms.
I understand and agree to the information shown above:
Signature__________________________________________________________Date_____________________________________
EMPLOYER SECTION:______________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
