Applicant Data How were you referred to us: Position applying for: Full Name: Address: City: State: Zip: Phone: Mobile/Pager/Other: E-mail: Date Available to Start: If you are under 18 years of age, can you provide a work permit?YesNo If no, please explain: Have you ever worked for this company?YesNo If yes, when? Are you legally allowed to work in the United States?YesNo Answering yes to these questions does not constitute an automatic rejection for employment. Type of employment desired (check all that apply):Full-TimePart-TimeTemporarySeasonal Education History Name & Location of High School: Did you graduate? Name & Location of College: Year attended: Degrees completed: Other Subjects Studied: Trade, Business or Correspondence School: Year attended: Subjects Studied: Did you graduate? Summarize Your Special Skills or Qualifications Previous Employment (begin with most recent position) Dates of Employment: From To Position(s) Held: Company Name: Address: City: State: Zip: Phone: Supervisor: Title: Responsibilities: Starting Title: Ending Title: Reason for leaving: May we contact this employer for a reference?YesNo Dates of Employment: From To Position(s) Held: Company Name: Address: City: State: Zip: Phone: Supervisor: Title: Responsibilities: Starting Title: Ending Title: Reason for leaving: May we contact this employer for a reference?YesNo Dates of Employment: From To Position(s) Held: Company Name: Address: City: State: Zip: Phone: Supervisor: Title: Responsibilities: Starting Title: Ending Title: Reason for leaving: May we contact this employer for a reference?YesNo "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (AIDA) and other relevant federal and state laws." Signature of Applicant (please type your full name below, by doing so you are agreeing with the above terms): Date:
