EMPLOYMENT / JOB APPLICATION 

I. PERSONAL INFORMATION.

FULL NAME: [EMPLOYEE’S NAME] DATE: [DATE]
ADDRESS: [ADDRESS]
E-MAIL: [E-MAIL] PHONE: [PHONE]
SOCIAL SECURITY NUMBER (SSN): [SSN]
DATE AVAILABLE: [DATE] DESIRED PAY: $[AMOUNT] ☐ HOUR ☐ SALARY
POSITION APPLIED FOR: [POSITION/TITLE]
EMPLOYMENT DESIRED: ☐ FULL-TIME ☐ PART-TIME ☐ SEASONAL

II. EMPLOYMENT ELIGIBILITY.

ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S? ☐ YES ☐ NO
HAVE YOU EVER WORKED FOR THIS EMPLOYER? ☐ YES ☐ NO
–IF YES, WRITE THE START AND END DATES: [START DATE] to [END DATE]
HAVE YOU EVER BEEN CONVICTED OF A FELONY? ☐ YES ☐ NO
-IF YES, PLEASE EXPLAIN: [EXPLAIN]

III. EDUCATION.

HIGH SCHOOL: [NAME] CITY / STATE: [LOCATION]
FROM: [START DATE] TO: [END DATE]
GRADUATE? ☐ YES ☐ NO DIPLOMA: [DIPLOMA TYPE]

COLLEGE: [NAME] CITY / STATE: [LOCATION]
FROM: [START DATE] TO: [END DATE]
GRADUATE? ☐ YES ☐ NO DEGREE: [DEGREE TYPE]

OTHER: [OTHER EDUCATION] CITY / STATE: [LOCATION]
FROM: [START DATE] TO: [END DATE]
DEGREE/CERTIFICATION: [DESCRIBE]

IV. PREVIOUS EMPLOYMENT.

EMPLOYER #1: [NAME OF EMPLOYER]
E-MAIL: [E-MAIL] PHONE: [PHONE]
ADDRESS: [ADDRESS]
START: $[AMOUNT] ☐ HOUR ☐ SALARY END: $[AMOUNT] ☐ HOUR ☐ SALARY
JOB TITLE: [TITLE] RESPONSIBILITIES: [DESCRIBE]
FROM: [START DATE] TO: [END DATE]
REASON FOR LEAVING: [DESCRIBE]

EMPLOYER #2: [NAME OF EMPLOYER]
E-MAIL: [E-MAIL] PHONE: [PHONE]
ADDRESS: [ADDRESS]
START: $[AMOUNT] ☐ HOUR ☐ SALARY END: $[AMOUNT] ☐ HOUR ☐ SALARY
JOB TITLE: [TITLE] RESPONSIBILITIES: [DESCRIBE]
FROM: [START DATE] TO: [END DATE]
REASON FOR LEAVING: [DESCRIBE]

EMPLOYER #3: [NAME OF EMPLOYER]
E-MAIL: [E-MAIL] PHONE: [PHONE]
ADDRESS: [ADDRESS]
START: $[AMOUNT] ☐ HOUR ☐ SALARY END: $[AMOUNT] ☐ HOUR ☐ SALARY
JOB TITLE: [TITLE] RESPONSIBILITIES: [DESCRIBE]
FROM: [START DATE] TO: [END DATE]
REASON FOR LEAVING: [DESCRIBE]

V. REFERENCES (PROFESSIONAL ONLY, NO FAMILY MEMBERS).

REFERENCE #1: [NAME OF REFERENCE] RELATIONSHIP: [DESCRIBE]
COMPANY: [COMPANY] TITLE: [TITLE]
E-MAIL: [E-MAIL] PHONE: [PHONE]

REFERENCE #2: [NAME OF REFERENCE] RELATIONSHIP: [DESCRIBE]
COMPANY: [COMPANY] TITLE: [TITLE]
E-MAIL: [E-MAIL] PHONE: [PHONE]

REFERENCE #3: [NAME OF REFERENCE] RELATIONSHIP: [DESCRIBE]
COMPANY: [COMPANY] TITLE: [TITLE]
E-MAIL: [E-MAIL] PHONE: [PHONE]

VI. MILITARY SERVICE.

ARE YOU A VETERAN? ☐ YES ☐ NO
BRANCH: [NAME OF BRANCH] RANK AT DISCHARGE: [RANK]
FROM: [START DATE] TO: [END DATE]
TYPE OF DISCHARGE: [DESCRIBE]
IF NOT HONORABLE, PLEASE EXPLAIN: [PROVIDE AN EXPLANATION]

VII. BACKGROUND CHECK CONSENT.

IF ASKED, WOULD YOU CONSENT TO A BACKGROUND CHECK? ☐ YES ☐ NO

VIII. DISCLAIMER.

Applicant understands that this is an equal opportunity employer and is committed to excellence through diversity. To ensure this application is acceptable, it is recommended to type and print your details.

Please complete each section, EVEN IF you decide to attach a resume.

I, the undersigned, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my termination.

SIGNATURE: ___________________________
DATE: ___________________________
PRINT NAME: ___________________________