Additional Information
Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us?
[ ] Y or [ ] N
If yes, please explain ___________________________________________
Employment History
Are you currently employed? [ ] Y or [ ] N
If you are currently employed, may we contact your current employer? [ ] Y or [ ] N
Below, please describe past and present employment positions, dating back five years. Please account for all periods of unemployment. Even if you have attached a resume, this section must be completed.
Name of Employer:______________________________________
Name of Supervisor:____________________________________
Telephone Number:______________________________________
Business Type:[ ________________________
Address:________________________
City, state, zip:________________________________
Length of Employment (Include Dates): _____________________
Position & Duties:_______________________________________________________
Reason for Leaving: _____________________________________________________________
May we contact this employer for references? [ ] Y or [ ] N
Name of Employer:______________________________________
Name of Supervisor:____________________________________
Telephone Number:______________________________________
Business Type: ________________________
Address:________________________
City, state, zip:________________________________
Length of Employment (Include Dates): _____________________
Position & Duties:_______________________________________________________
Reason for Leaving: _____________________________________________________________
May we contact this employer for references? [ ] Y or [ ] N
Name of Employer:______________________________________
Name of Supervisor:____________________________________
Telephone Number:______________________________________
Business Type: ________________________
Address:________________________
City, state, zip:________________________________
Length of Employment (Include Dates): _____________________
Position & Duties:_______________________________________________________
Reason for Leaving: _____________________________________________________________
May we contact this employer for references? [ ] Y or [ ] N
References
List below three persons who have knowledge of your work performance within the last four years. Please include professional references only.
Name - First, Last: ______________________________________
Telephone Number:____________________________
Address:________________________
City, state, zip:________________________________
Occupation: ______________________________________
Number of Years Acquainted: ______________________________________
Name - First, Last: ______________________________________
Telephone Number:____________________________
Address:________________________
City, state, zip:________________________________
Occupation: ______________________________________
Number of Years Acquainted: ______________________________________
Name - First, Last: ______________________________________
Telephone Number:____________________________
Address:________________________
City, state, zip:________________________________
Occupation: ______________________________________
Number of Years Acquainted: ______________________________________
Please Read and Initial Each Paragraph, then Sign Below
I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true & correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure can be grounds for rejection of application or, if I am employed by this company, terms for my immediate expulsion from the company._____
I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or the company.
_____
I permit the company to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers & all other persons, corporations, partnerships & associations from any & all claims, demands or liabilities arising out of or in any way related to such examination or revelation.
_____
Applicant's Signature:______________________________
Date:_________________________________
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Please Note: This sample is provided for guidance only. The provided information, including samples and examples, is not guaranteed for accuracy or legality. Letters and other correspondence should be edited to fit your personal situation.
