Sample Employment Application Form

PLEASE PRINT ALL

INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS

PLEASE COMPLETE PAGES 1-5. DATE __________________________________

Name ________________________________________________________________________________________________
Last First Middle Maiden

Present address ________________________________________________________________________________________

Number Street City State Zip

How long _____________________ Social Security No. _______ – _____ – _________

Telephone ( )

If under 18, please list age ______________________

Days/hours available to work

Position applied for (1)_________________________ No Pref ________ Thur __________
and salary desired (2) _________________________ Mon ___________ Fri ___________
(Be specific) Tue ___________ Sat ___________
Wed ___________ Sun __________

How many hours can you work weekly? __________________________ Can you work nights? _________________________

Employment desired qFULL-TIME ONLY qPART-TIME ONLY qFULL- OR PART-TIME

When available for work?________________

_____________________________________________________________________________________________________

TYPE OF SCHOOL NAME OF SCHOOL LOCATION NUMBER OF YEARS MAJOR &

(Complete mailing COMPLETED DEGREE
address)
High School

College

Bus. or Trade School

Professional School

HAVE YOU EVER BEEN CONVICTED OF A CRIME? q No q Yes

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were
committed, sentence(s) imposed, and type(s) of rehabilitation. ____________________________________________________

_____________________________________________________________________________________________________
 PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT

DO YOU HAVE A DRIVER’S LICENSE? q Yes q No

What is your means of transportation to work? ________________________________________________________________

Driver’s license
number ______________________________ State of issue _______ q Operator q Commercial (CDL) qChauffeur
Expiration date ________________________

Have you had any accidents during the past three years? How many? ____________________
Have you had any moving violations during the past three years? How Many? ____________________

OFFICE ONLY

q Yes q Yes Word q Yes

Typing q No _____ WPM 10-key q No Processing q No _____ WPM

Personal q Yes PC q Other ______________________________________________

Computer q No Mac q Skills ______________________________________________

Please list two references other than relatives or previous employers.

Name _________________________________________ Name ______________________________________________

Position ________________________________________ Position ____________________________________________

Company ______________________________________ Company ___________________________________________

Address _______________________________________ Address ____________________________________________

_______________________________________ ____________________________________________

Telephone ( ) Telephone ( )

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the
space below to summarize any additional information necessary to describe your full qualifications for the specific position for
which you are applying.
 PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
MILITARY

HAVE YOU EVER BEEN IN THE ARMED FORCES? q Yes q No

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? q Yes q No

Specialty ____________________________________ Date Entered __________________ Discharge Date ________________

Work Please list your work experience for the past five years beginning with your most recent job held.
Experience If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of employer Name of last Employment dates Pay or salary

Address supervisor
City, State, Zip Code
Phone number From Start

To Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Name of employer Name of last Employment dates Pay or salary

Address supervisor
City, State, Zip Code
Phone number From Start

To Final

Your Last Job Title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.
 PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
Work Please list your work experience for the past five years beginning with your most recent job held.
experience If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of employer Name of last Employment dates Pay or salary

Address supervisor
City, State, Zip Code
Phone number From Start

To Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Name of employer Name of last Employment dates Pay or salary

Address supervisor
City, State, Zip Code
Phone number From Start

To Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

May we contact your present employer? q Yes q No

Did you complete this application yourself q Yes q No

If not, who did? _________________________________________________________________________________________

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by ___________________ (hereinafter called “the
Company”), I agree that:
Neither the acceptance of this application nor the subsequent entry into any type of employment
relationship, either in the position applied for or any other position, and regardless of the contents of
employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist
from time to time, or other Company practices, shall serve to create an actual or implied contract of
employment, or to confer any right to remain an employee of , or otherwise to change in any
respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be
altered except by a written instrument signed by the President /General Manager of the Company. Both the
undersigned and may end the employment relationship at any time, without specified notice
or reason. If employed, I understand that the Company may unilaterally change or revise their benefits,
policies and procedures and such changes may include reduction in benefits.
I authorize investigation of all statements contained in this application. I understand that the
misrepresentation or omission of facts called for is cause for dismissal at any time without any previous
notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise
indicated), references, and others, and hereby release the Company from any liability as a result of such
contract.
I also understand that (1) the Company has a drug and alcohol policy that provides for preemployment
testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of
my employment; and (3) continued employment is based on the successful passing of testing under such
policy. I further understand that continued employment may be based on the successful passing of job-
related physical examinations.
I understand that, in connection with the routine processing of your employment application, the Company
may request from a consumer reporting agency an investigative consumer report including information as to
my credit records, character, general reputation, personal characteristics, and mode of living. Upon written
request from me, the Company, will provide me with additional information concerning the nature and scope
of any such report requested by it, as required by the Fair Credit Reporting Act.
I further understand that my employment with the Company shall be probationary for a period of sixty (60)
days, and further that at any time during the probationary period or thereafter, my employment relation with
the Company is terminable at will for any reason by either party.

Signature of applicant__________________________________________ Date: ___________________

This Company is an equal employment opportunity employer. We adhere to a policy of making employment
decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or
disability. We assure you that your opportunity for employment with this Company depends solely on your
qualifications.

Thank you for completing this application form and for your interest in our business.
 PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE

POST EMPLOYMENT INFORMATION FORM

TO BE COMPLETED AFTER EMPLOYEE HAS BEEN HIRED

Height ______ ft. ______ in. Weight __________ Birth date _______________

Married q Yes q No If married, how long? _____ q Single q Separated qDivorced qWidowed

Full name of spouse __________________________________ Occupation ________________________________________

Name of company ____________________________________ Telephone ( )

PERSON TO BE NOTIFIED IN CASE OF EMERGENCY

Name _____________________________________________ Telephone ( )

Address ____________________________________________ Relationship _______________________________________

FOR INSURANCE PURPOSES ONLY: LIST ALL DEPENDENTS

NAME RELATIONSHIP BIRTH DATE SSN

TO BE COMPLETED
BY EMPLOYER

Date of employment ___________________ Job title ______________________ Dept. _______________________________

Location______________________________ Rate of pay ___________________ q Full-time q Part-time q Salaried

Applicant’s signature acknowledging above information _________________________________________________________

Drug test confirmation number _________________________________

Name of person verifying information _______________________________________________________________________

Name of person authorizing employment ____________________________________________________________________

 Applicant Selection Criteria Record

JOB TITLE

CANDIDATES CONSIDERED (INCLUDING MINORITIES AND FEMALES)

NAME MALE/ ETHNIC ON LAB

SECTION/ OFF
FEMALE CODE* LAB

*ETHNIC CODES: 1-BLACK, 2-ORIENTAL, 3-HISPANIC, 4-AMERICAN INDIAN, 0-OTHER

CANDIDATE SELECTED

NAME MALE/ ETHNIC SOURCE

FEMALE CODE

SELECTION CRITERIA

REASONS CANDIDATE SELECTED WAS PREFERABLE TO OTHERS

ORIGINATOR'S SIGNATURE DATE