Application for Employment

Equal access to programs, services and employment opportunities is available to all persons without regard to age, race, creed, religion, color, national origin, sexual orientation, military status, sex (including pregnancy), disability, familial status, marital status, domestic violence victim status, genetic information, or any other basis protected by federal, state, and/or local law. In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include making a change to the application process; providing written materials in an alternate format such as braille, large print, or audio recording; using a sign language interpreter; using specialized equipment; or modifying testing conditions.
First Name*
Middle Name
Last Name*
Street Address*
Address*
City State ZIP Code
Email Address*
Phone Number (Home)*
Phone Number (Cell)
Position(s) applied for
Referral Source

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If necessary, best time to call you is:
Phone Number
May we contact you at work?
- Yes
- No
Best time to call you at work is:
Work Phone Number
Ext.

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Are you able to perform the “essential functions” of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.
- Yes
- No
- Need more information

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Starting with your most recent employer, provide the following information.

Employer	Phone	Address	Final Job Title	Actions

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Summarize any special training, skills, languages, licenses, bonding, certifications, and/or certificates that may assist you in performing the position for which you are applying:
Computer Skills (include software titles and level of experience, such as basic, intermediate, or advanced.)

Software Name	Skill Level	Actions

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School Name	Major/Minor/Certificate	Actions

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Name	Title	E-mail Address	Actions

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When answering these questions, please exclude any information that would reveal age, race, creed, religion, color, national origin, sexual orientation, military status, sex (including pregnancy), disability, familial status, marital status, domestic violence victim status, genetic information, or other similarly protected status.
To what job-related organizations (professional, trade, etc.) do you belong?
List any relevant volunteer work:
List special accomplishments, publications, awards, etc.:
Is there any other job-related information you want us to know about you?

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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 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, résumé, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law. I understand that this application remains current for only 60 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 for me 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 with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or 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 supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements 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 identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer's affiliate(s) and third parties engaged by the employer to perform services for the employer. Any personal information shared with an affiliate or third party is to be used solely to perform the services requested by the employer. This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her age, race, creed, religion, color, national origin, sexual orientation, military status, sex (including pregnancy), disability, familial status, marital status, domestic violence victim status, genetic information, or any other protected status under applicable federal, state, or local law. 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 (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.
Signature*
Date*
MM slash DD slash YYYY

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Application for Employment.

Step 1 of 11 - Personal Information