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List names of employers in consecutive order with present or last employer listed first. Account for all periods of time
including military service and any periods of unemployment. if self-employed, give firm name and supply business
references.
Note: A job offer may be contingent upon acceptable references from current and former employers.
NAME OF EMPLOYER JOB TITLE AND DUTIES
ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM TO
CITY, STATE, ZIP CODE
PAY: START $ FINAL $
SUPERVISOR(S) TELEPHONE Reason For Leaving
NAME OF EMPLOYER JOB TITLE AND DUTIES
ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM TO
CITY, STATE, ZIP CODE
PAY: START $ FINAL $
SUPERVISOR(S) TELEPHONE REASON FOR LEAVING
NAME OF EMPLOYER JOB TITLE AND DUTIES
ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM TO
CITY, STATE, ZIP CODE
PAY: START $ FINAL $
SUPERVISOR(S) TELEPHONE REASON FOR LEAVING
NAME OF EMPLOYER JOB TITLE AND DUTIES
ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM TO
CITY, STATE, ZIP CODE
PAY: START $ FINAL $
SUPERVISOR(S) TELEPHONE REASON FOR LEAVING
Have you worked or attended school under any other names ......................... Yes No
If yes, give names: _________________________________________________________________________________________
Are you presently employed ................................................ Yes
No
If yes, whom do you suggest we contact ____________________________________________________________________
Have you ever been fired from a job or asked to resign.............................. Yes
No
If yes, please explain: _______________________________________________________________________________________
Give three references, not relatives or former employers.
Name Address Phone
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING
I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further
consideration for employment and may result in my dismissal if discovered at a later date.
I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers
and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in
making such statements.
I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of
employment, if required.
I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to
the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.
I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED
CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZATION HAS THE AUTHORITY
TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE PRESIDENT AND THE
EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH
OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.
I have read, understand, and by my signature consent to these statements.
Signature: ________________________________________________________________________________________________________________ Date: _________________________________
This application for employment will remain active for a limited time. Ask the organization’s representative for details.
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