Application for Employment
Equal access to programs, services, and employment is available to all persons. Those requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.
PERSONAL INFORMATION
(Please Print Clearly)
Position applied for:____________________________________ |
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Date:______________________ |
Name:_________________________________________________________ |
Social Security#:____________________ |
Address:________________________________________________________________________________________ |
Street |
City |
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State/Zip Code |
Telephone#:___________________________________________ |
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Cell Phone:________________________ |
If you are under 18, and it is required, can you furnish a work permit? |
________ |
Yes |
________ No |
Are you legally eligible to work in the U.S.? |
________ |
Yes |
_______ |
No |
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Date available for work:_______________________ |
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Desired salary range $___________________ |
Type of employment desired: _________Full-Time |
________Part-Time |
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Do you have any relatives employed by Factory Connection: |
________ |
Yes |
_______ |
No |
If yes, please provide the name and relationship to you:_________________________________________________
BACKGROUND INFORMATION
Have you ever been convicted of, pled guilty to, or admitted guilt to a crime? _____Yes ____No
Answering yes to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be taken into account.
If you answered yes to the above question supply the following information:
Date of Offense:_____________________ Indicate the nature of the conviction:____________________________
________________________________________________________________________________________________.
Have you ever been discharged from a position, or resigned to avoid discharge? ____Yes ____No
If yes describe circumstances:______________________________________________________________________
_________________________________________________________________________________________________.
EDUCATIONAL HISTORY
Are you currently enrolled in school? |
____Yes ____No If yes, where:______________________________ |
Indicate the highest level of education you have completed. |
_____ |
Have a high school diploma from:____________________________________________________________ |
_____ |
Have my GED |
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_____ |
Have a college or technical degree from:______________________________________________________ |
_____ |
Did not graduate high school and do not have my GED |
EMPLOYMENT HISTORY
Provide the following information of your past (4) employers, assignments, or volunteer activities, starting with the most recent.
Current or Most Recent Employer
Employer:______________________________________________ Employer Phone:____________________________
Employer Address:_________________________________________________________________________________
StreetCityState Zip
Exact Position Title:_____________________________________ Average Hours per Week:______________________
Hourly/Salary Amount:__________________________ |
Still Employed: |
____Yes ____No |
Date Started:___________________________________ |
Date Ended:__________________________________ |
Reason for Leaving:_________________________________________________________________________________
Supervisor's Name:______________________________________ Supervisor's Phone:__________________________
Duties:____________________________________________________________________________________________
May Factory Connection contact this employer about your character, qualifications and employment record?
____Yes ____No
Second Most Recent Employer
Employer:______________________________________________ Employer Phone:____________________________
Employer Address:_________________________________________________________________________________
StreetCityState Zip
Exact Position Title:_____________________________________ Average Hours per Week:______________________
Hourly/Salary Amount:__________________________ |
Still Employed: |
____Yes ____No |
Date Started:___________________________________ |
Date Ended:__________________________________ |
Reason for Leaving:_________________________________________________________________________________
Supervisor's Name:______________________________________ Supervisor's Phone:__________________________
Duties:____________________________________________________________________________________________
May Factory Connection contact this employer about your character, qualifications and employment record?
____Yes ____No
Third Most Recent Employer
Employer:______________________________________________ Employer Phone:____________________________
Employer Address:_________________________________________________________________________________
StreetCityState Zip
Exact Position Title:_____________________________________ Average Hours per Week:______________________
Hourly/Salary Amount:__________________________ |
Still Employed: |
____Yes ____No |
Date Started:___________________________________ |
Date Ended:__________________________________ |
Reason for Leaving:_________________________________________________________________________________
Supervisor's Name:______________________________________ Supervisor's Phone:__________________________
Duties:____________________________________________________________________________________________
May Factory Connection contact this employer about your character, qualifications and employment record?
____Yes ____No
Fourth Most Recent Employer
Employer:______________________________________________ Employer Phone:____________________________
Employer Address:_________________________________________________________________________________
StreetCityState Zip
Exact Position Title:_____________________________________ Average Hours per Week:______________________
Hourly/Salary Amount:__________________________ |
Still Employed: |
____Yes ____No |
Date Started:___________________________________ |
Date Ended:__________________________________ |
Reason for Leaving:_________________________________________________________________________________
Supervisor's Name:______________________________________ Supervisor's Phone:__________________________
Duties:____________________________________________________________________________________________
May Factory Connection contact this employer about your character, qualifications and employment record?
____Yes ____No
UNEMPLOYMENT
Please explain all periods of unemployment in the spaces below. Attach additional sheets if necessary.
From:___________ |
To:__________ |
Reason:________________________________________________ |
From:__________ |
To:__________ |
Reason:________________________________________________ |
REFERENCES
Please provide three work references. If you do not have work references, you may include educational references. Do not include family members as references.
______________________________________________________________________________________________
NameRelationship to youPhone
______________________________________________________________________________________________
NameRelationship to youPhone
______________________________________________________________________________________________
NameRelationship to youPhone
REFERRED TO FACTORY CONNECTION BY:
Hiring signs |
_________ |
Walk-in |
_________ |
Internet |
_________ |
Newspaper ad |
_________ |
Factory Connection Associate - name/location |
_____________________________________________ |
SKILLS AND QUALIFICATIONS
Summarize any training, skills, license, and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
APPLICANT'S STATEMENT
I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (1) cancel further consideration for application, or (2) immediately discharge me from the employer's service, whenever it is discovered. I expressly authorize, without reservation, the employer, its representatives, employees, or agents, to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I herby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using such information in the employment process and all other person, corporations, or organizations for furnishing such information about me. I understand that 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 applicable local, state, or federal law. I understand that if offered a position with Factory Connection, I may be required to submit to a pre-employment medical examination, drug screening
and background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these employment tests and checks will result in withdrawal of any employment offer or terminate employment if already employed. I understand that this application remains current
for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and 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 any agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer's are authorized to make any assurances to the contrary and that no implied, oral, or written agreement contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president. I also understand that if I am hired, I will be required to provide proof of identify and legal authority to work in the Untied States and that federal immigration
laws require me to complete an I-9 form in this regard.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT
I certify that I have read, fully understand, and accept all terms of the foregoing Applicant Statement:
Signature
Mark the appropriate response to each statement or question. (T=True; F=False)
1. |
It is sometimes necessary to tell small lies to stay out of trouble. |
___T |
___F |
2. |
I have stolen a few things from my employers in the past. |
___T |
___F |
3. |
If I discover I am $10 over in my register at the end of the day it's ok |
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to take that money out of the register and keep it to make my register balance. |
___T |
___F |
4. |
It's ok to give my friends my employee discount as long as I don't do it often. |
___T |
___F |
Please answer the following questions using a scale of 1 to 10 with 1 indicating you strongly disagree and 10 being you strongly agree.
1.If I'm too tired to drop the required nightly deposit it will be allright to do it the next day. Answer: (Answer using scale 1-10)____________________________________________
2.The store opens at 10:00. If I arrive at 10:00 I will not be tardy.
Answer: (Answer using scale 1-10)____________________________________________
3. I am a great employee if I greet 50% of the customers.
Answer: (Answer using scale 1-10)____________________________________________
4. I should be able to leave the store anytime I need to, even if I have to close it.
Answer: (Answer using scale 1-10)____________________________________________
