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Application for Employment
Our policy is to provide equal employment opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, ancestry, physical or mental disability, or veteran status.
Ngày ______________
Last name ________________________ First name ________________ Middle name________
Street Address _________________________________________________________________
City _____________________ State _______ ZIP _______ 
Telephone ___________________________ Social Security # ___________________________ 
Position applied for __________________________________________
How did you hear of this opening? __________________________________________ 
When can you start? _____________________ Desired Wage $______________ 
Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation.) q Yes q No 
Are you looking for full-time employment? q Yes q No 
If no, what hours are you available? ______________
Are you willing to work swing shift? q Yes q No 
Are you willing to work graveyard? q Yes q No 
Have you ever been convicted of a felony? (This will not necessarily affect your application.) q Yes q No 
If yes, please describe conditions. __________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Education	
School Name and Location 	 	 	Year Major Degree
High School ________________________________________	______ ______ ______
College ___________________________________________	______ ______ ______
College ___________________________________________	______ ______ ______
Post-College _______________________________________	______ ______ ______
Other Training ______________________________________ 	______ ______ ______
In addition to your work history, are there other skills, qualifications, or experience that we should consider? ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Employment History 	(Start with most recent employer)
Company Name ________________________________________________________________ 
Address ____________________________________ Telephone _________________________
Date Started ___________ Starting Wage ____________ Starting Position ________________
Date Ended _____________ Ending Wage ____________ Ending Position ________________
Name of Supervisor ____________________________________ 
May we contact? q Yes q No
Responsibilities _______________________________________________________________
_____________________________________________________________________________
Reason for leaving ______________________________________________________________
Company Name ________________________________________________________________ 
Address ________________________________________ Telephone _____________________
Date Started ____________ Starting Wage ____________ Starting Position _______________ 
Date Ended _____________ Ending Wage ____________ Ending Position ________________
Name of Supervisor ____________________________________ 
May we contact? q Yes q No
Responsibilities ________________________________________________________________
______________________________________________________________________________
Reason for leaving ______________________________________________________________
Company Name _______________________________________________________________ 
Address _______________________________________ Telephone ______________________
Date Started ____________ Starting Wage ____________ Starting Position _______________ 
Date Ended _____________ Ending Wage ____________ Ending Position ________________
Name of Supervisor ____________________________________ 
May we contact? q Yes q No
Responsibilities ________________________________________________________________
______________________________________________________________________________
Reason for leaving ______________________________________________________________
Company Name ________________________________________________________________ 
Address _______________________________________ Telephone ______________________
Date Started ____________ Starting Wage ____________ Starting Position _______________ 
Date Ended _____________ Ending Wage ____________ Ending Position ________________
Name of Supervisor ____________________________________ 
May we contact? q Yes q No
Responsibilities ________________________________________________________________
______________________________________________________________________________
Reason for leaving ______________________________________________________________
Attach additional information if necessary.
I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements on this application shall be considered sufficient cause for dismissal. This company is hereby authorized to make any investigations of my prior educational and employment history. 
I understand that employment at this company is “at will,” which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager, or executive of this company, other than the president, has any authority to alter the foregoing.
Signature_______________________________________________ Date _________________