Position(s) applied for

Date of application

YYYY

Referral source

Employee

Relative

Government Employment Agency

Walk-In

Private Employment Agency

Other

If other, please list name of source (If applicable)

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email address

Social Security Number

Telephone

(###)

###

####

If necessary, best time to call you at home is

Work number

(###)

###

####

May we contact you at work?

Yes

If yes, best time to call you at work is

If you are under 18, can you furnish a work permit?

Yes

Have you filed an application here before?

Yes

If yes, give date

YYYY

Have you ever been employed here before?

Yes

If yes, give dates

From

YYYY

Are you legally eligible for employment in this country?

(Proof of U.S. citizenship or Immigration status will be required upon employment.)

Yes

Date available for work

YYYY

Lowest salary you would accept?

Type of employment desired:

Full time

Part time

Temporary

Please state acceptable localities (cities and counties)

Are you on a lay-off and subject to recall?

Yes

Will you relocate if the job requires it?

Yes

Will you travel if the job requires it?

Yes

Will you work overtime if required?

Yes

Please be advised that if you are applying for a driving position, you will need to undergo a pre-employment physical, pursuant to federal law. If this is not acceptable to you, please check "No".

Yes

Have you ever been bonded?

Yes

Have you ever pled guilty or been convicted of a felony or misdemeanor?

(Please note that a conviction will not automatically exclude you from consideration for employment.)

Yes

If yes, please explain.

Driver's license number (If required by job)

Driver's license state

Employment History

List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in the comments section below.

Employer 1: Telephone

(###)

###

####

Employer 1: Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer 1: Job Title

Employer 1: Immediate Supervisor and Title

Employer 1: Reason for leaving

Employer 1: May we contact for reference?

Yes

Later

Employer 1: Dates employed

From

YYYY

Employer 1: Hourly Rate / Salary

Starting

Employer 1: Hourly Rate / Salary

Final

Employer 1: Summarize the nature of the work performed and job responsibilities.

Employer 2

Employer 2: Telephone

(###)

###

####

Employer 2: Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer 2: Job Title

Employer 2: Immediate Supervisor and Title

Employer 2: Reason for leaving

Employer 2: May we contact for reference?

Yes

Later

Employer 2: Dates employed

From

YYYY

Employer 2: Hourly Rate / Salary

Starting

Employer 2: Hourly Rate / Salary

Final

Employer 2: Summarize the nature of the work performed and job responsibilities.

Employer 3

Employer 3: Telephone

(###)

###

####

Employer 3: Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer 3: Job Title

Employer 3: Immediate Supervisor and Title

Employer 3: Reason for leaving

Employer 3: May we contact for reference?

Yes

Later

Employer 3: Dates employed

From

YYYY

Employer 3: Hourly Rate / Salary

Starting

Employer 3: Hourly Rate / Salary

Final

Employer 3: Summarize the nature of the work performed and job responsibilities.

Employer 4

Employer 4: Telephone

(###)

###

####

Employer 4: Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer 4: Job Title

Employer 4: Immediate Supervisor and Title

Employer 4: Reason for leaving

Employer 4: May we contact for reference?

Yes

Later

Employer 4: Dates employed

From

YYYY

Employer 4: Hourly Rate / Salary

Starting

Employer 4: Hourly Rate / Salary

Final

Employer 4: Summarize the nature of the work performed and job responsibilities.

Comments (including explanation of any gaps in employment)

Skills and Qualifications

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for work with our Company.

Employment Background

List last three (3) schools attended starting with last one.

School A: Number of years completed

School A: Degree or diploma earned, if any

School A: Grade Point Average or class rank

School A: Major

School A: Minor

School B

School B: Number of years completed

School B: Degree or diploma earned, if any

School B: Grade Point Average or class rank

School B: Major

School B: Minor

School C

School C: Number of years completed

School C: Degree or diploma earned, if any

School C: Grade Point Average or class rank

School C: Major

School C: Minor

Foreign Language

List any foreign language(s)

Language 1

Select all that apply

Read and write

Read and speak

Read only

Speak only

Language 2

Select all that apply

Read and write

Read and speak

Read only

Speak only

Language 3

Select all that apply

Read and write

Read and speak

Read only

Speak only

References

List three (3) 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: Telephone

(###)

###

####

Reference 1: Years known

Reference 2

Reference 2: Telephone

(###)

###

####

Reference 2: Years known

Reference 3

Reference 3: Telephone

(###)

###

####

Reference 3: Years known

Organizations

List professional, trade, business or civic organizations with which you have been associated and that you consider relevant to your ability to do this job. (Exclude memberships which would reveal sex, race, religion, national origin, age, ancestry or other protected status.)

Organization 1: Offices held

Organization 2

Organization 2: Offices held

Organization 3

Organization 3: Offices held

List special accomplishments, publications, awards.

(Exclude membership which would reveal, sex, race, religion, national origin, age, ancestry or other protected status.)

List any additional information you would like us to consider.

It is understood and agreed that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed. Furthermore, I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary. I give the Employer the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all the other persons, corporations or organizations for furnishing such information. The Employer is an equal opportunity employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excluding any applicant’s consideration for employment on a basis prohibited by local, state, or federal law. This application is current for only sixty (60) days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary for me to fill out a new application.

Signature of Applicant

Thank you!

Mid-Cumberland Application for Employment