Referral Source

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Name      Date of application
Last First Middle

Address      Email
Street City State Zip

Please indicate the best No./Time to contact

Home Phone : AMPM Cell Phone : AMPM Work Phone : AMPM

Date available for work Type of employment desired Full Time Part Time Temporary

A. List last three (3) schools attended, starting with most recent. B. List number of years completed. C. Indicate degree or diploma earned, if any. D. Grade Point Average or Class Rank. E. Major field of study. F. Minor field of study (if applicable).

Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform the job-related functions in the position for which you are applying.

Special accomplishments, publications, awards, etc. (exclude information which would reveal sex, race, religion, nation origin, age, color, disability or other protected status.)

List any additional information you would like us to consider.

Provide the following information about your past and current employers, assignments or volunteer activities, starting with the most recent (use additional sheets if necessary). Explain any gaps in employment in the comments section below.

Comments

List name and telephone number of three business/work references who are NOT related to you and are NOT previous supervisors. If not applicable, list three school or personal references who are NOT related to you.

I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer’s service, whenever it is discovered.

I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information.

The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer.

I understand it is the company’s policy not to refuse to hire a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.

Please type your name and date. Name  Date 

AN EQUAL OPPORTUNITY EMPLOYER