Application for Employment

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Referral Source
Please check the appropriate category or categories
If you can, please provide any details on how you were referred

Extended Info

If necessary, the best time to call you is...
Best Call Phone
May we contact you at work?
If yes, your work number
...and best time to call
If you are under 18 and it is required, can you furnish a work permit?
If no please explain
Have you submitted an application here before?
If yes, give date(s) and position(s)
Have you ever been employed here before?
If yes, give dates
Is this application a request for reemployment following an extended military leave of absence from this company?
If yes, additional information may be requested
Are you legally eligible for employment in this country?
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Type of employment desired
Will you relocate if the job requires it?
Will you travel if the job requires it?
If they have been explained to you, are you able to meet the attendance requirements of this position?
Will you work overtime if required?
If no, please explain
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.
Required if driving may be required in the job for which you are applying
Required if driving may be required in the job for which you are applying
Have you ever been bonded?
Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?
If yes, please explain
This company is subject to the state’s workers’ compensation laws (Chapter 29-38) unless otherwise noted below: (list applicable exemptions)

Employment History

Starting with your most recent employer, provide the following information. You may include any verified work performed on a volunteer basis.

Employer 1

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May we contact for reference?

Employer 2

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May we contact for reference?

Employer 3

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May we contact for reference?

Employer 4

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May we contact for reference?

Employment History (continued)

If not addressed on previous page, have you ever been fired or asked to resign from a job?
If yes, please explain

Skills and Qualifications

Computer Skills
Please enter appropriate skills you have which may apply to the position you're seeking. For each, enter skill type and if applicable, the specific software name, along with with your years of experience. "Word Processing" or "Spreadsheets" are a few examples of skill types. Click the plus to add more skills as necessary.
Skill type
Software name (if applicable)
Years experience
 

Educational Background

Starting with your most recent school attended, provide the following information:
Click the plus to add more schools as necessary.
School (include city and state)
Years completed
Degree/certificate
GPA/class Rank
Major/minor
 

References

List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

Reference 1

Reference 2

Reference 3

Related Information

To what job-related organizations (professional, trade, etc.) do you belong?
Exclude memberships that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status. Click the plus to add further organizations.
Organization
Offices held
 
Exclude information that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status.
In your current or a previous job, have you ever written instructions or directions to be followed by employees or customers?
If yes, please explain

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this 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, resumé 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 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 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.

Mandatory Employer Disclosures

Notice to Maryland applicants: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

Notice to Massachusetts applicants: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

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 sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

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 of Applicant*
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
Date
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