APPLICATION FOR EMPLOYMENT
It is the policy of this company to provide equal employment opportunities to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, physical or mental handicap or veteran status. PLEASE PRINT.
PERSONAL DATA
POSITION(S) APPLYING FOR: ________________________________________ Date ________________
Name: _______________________________________________________________________________________
FirstMiddleLast
Address: ____________________________________________________________________________________
Street and Apt. #CityStateZip Code
Phone Number: ________________________________ |
_________________________________ |
Daytime |
Evening |
Social Security #: __________________ Driver’s License #: ________________State: ____Expires ___________
How did you hear about this position? ________________________________________________________________
Salary Desired? _____________________ Can you prove you are a U.S. Citizen or otherwise authorized to
work in the United States on an unrestricted basis: Yes ______ No ______
If applicable, please list your visa type, visa # and expiration: ____________________________________
If under 18 years of age, can you furnish a work permit if required? __________ If, not please explain
If hired, are you able to get to work and meet attendance requirements every day? ___________________
Have you been convicted of a felony in the last five years? _______ If so, please explain.
(Conviction does not automatically bar you from employment consideration.)
Type of employment wanted: Full Time_____ Part Time ____ Temporary ____
Date available for work: ____ What hours do you prefer to work? _________________________________
Can you work overtime, if required? _____ Weekends if required? _____ Please list hours you cannot
work ________________________ Will you relocate if the job requires it? ______
Will you travel if required? _____ How many days of work or school have you missed in the last year for
reasons other than sickness? _____ Please explain:
EDUCATION BACKGROUND Please circle the highest level of education attained.
Elementary 1-5 Junior High 6 7 8 High School 9 10 11 12 G.E.D Technical/Trade School (which field?)
_____________________________________ Military Education ____________________________
College 1 2 3 4 College Name and City _____________________ Graduate School ______________
Are you currently in school? __ What level? ___ Summarize special training or skills that may qualify you
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
EMPLOYMENT HISTORY Please list your last four employers, starting with the most recent.
1. EmployerAddressPhoneJob Title/Position
____________________________________________________________________________________
Supervisor’s Name & Title: _____________________ Reason for leaving _________________________
Describe Duties: ______________________________________________________________________
Start Date: _______ End Date: ______ Starting Salary/Hrly. Rate: _____ Ending Salary/Hrly. Rate: _____
2. EmployerAddressPhoneJob Title/Position
____________________________________________________________________________________
Supervisor’s Name & Title: _____________________ Reason for leaving _________________________
Describe Duties: ______________________________________________________________________
Start Date: _______ End Date: ______ Starting Salary/Hrly. Rate: _____ Ending Salary/Hrly. Rate: _____
3. EmployerAddressPhoneJob Title/Position
____________________________________________________________________________________
Supervisor’s Name & Title: _____________________ Reason for leaving _________________________
Describe Duties: ______________________________________________________________________
Start Date: _______ End Date: ______ Starting Salary/Hrly. Rate: _____ Ending Salary/Hrly. Rate: _____
4. EmployerAddressPhoneJob Title/Position
____________________________________________________________________________________
Supervisor’s Name & Title: _____________________ Reason for leaving _________________________
Describe Duties: ______________________________________________________________________
Start Date: _______ End Date: ______ Starting Salary/Hrly. Rate: _____ Ending Salary/Hrly. Rate: _____
Please explain any employment gaps found above:___________________________________________
May we contact the employers listed above?____ If there are any you don’t wish us to contact, please list:
____________________________________________________________________________________
I hereby certify that my answers and assertions set forth in this application are true and complete to the best of my knowledge. If I am employed, I understand that any false statements on this application shall be considered sufficient cause for my dismissal. I hereby authorize this company to investigate any aspect of my prior educational and employment history.
Furthermore I understand that if I am hired, employment with this company is "at will," which means that either the company or I can terminate my employment for any reason not prohibited by state or federal law. After termination of my employment, for whatever reason, I release the above employer from liability for any information supplied to future potential employers.
Signature: ___________________________________________ |
Date: _____________________ |
Please drop this application off at the Jiffy lube where you are applying for work.
