Employment Employment Application

[Your Company Name] Employment Application We Are An Equal Opportunity Employer; referred to herein as “Potential Employer.” Please Print and fill out all three pages. Name : (Last) (First) (Middle) Social Security Number Home Telephone Email Driver’s License Number: Cell Phone/Pager: Present Address No. Street Apt# City State Zip Permanent Address if different from present address (Complete same as above) Employment Desired Position(s) Applying for: Sales Executive Accounting/Collections Credit Analyst Customer Service Funding Coordinator Receptionist Other: __________ I am applying for: • Regular full-time Regular part-time work When are you available to work (days and hours)? ______________________________ • Would you be interested in working overtime? Yes No • If hired, on what date can you begin work? • Desired Salary: Personal Information • How did you find out about our company? __________________________________________________________________ • Do you know anyone, friend or relative, who is working for our company? Yes No • If yes, please write name(s) and relationship ________________________________________________ • If hired, would you have a reliable means of transportation to and from work? Yes No • Are you at least 18 years of age? (If under 18, hire is subject to verification that you are of minimum legal age to work.) Yes No • If hired, can you show evidence of your U.S. citizenship or proof of your legal right to live and work in the United States? Yes No • Are you capable of performing the essential functions of the job for which you are applying? Yes No • If no, please write in detail the functions that cannot be performed.* ____________________________________ *(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicant/employees to perform essential functions.) Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? Yes No If yes, please give the nature of the crime(s), when and where convicted and disposition of the case. ___________________________________ _________________________________________________________________ Education, Training and Experience School Name and No. of Did you Graduate? Degree or Address Years When? Diploma High School College/University Undergrad College/University Graduate Vocational/Business Is there anything you have experience or training in that the application has not allowed you to express? Please explain below. __________________________________________________________________ ________________________________________ ______________________________ Military Service Have you learned any specific special skills or abilities during service in the military? Yes No If so, describe: ________________________________________________ Employment History Have you even been involved in a legal proceeding involving a current or previous employer? Yes No If yes, then please explain why. ____________________________________________________________ List Below all present and past employment starting with your most recent employer (last 10 years is sufficient). Account for all periods of unemployment. Regardless of whether or not you attach a resume, you must complete this section. If you cannot complete the entire section about previous employers, please fax or call over the missing information to us immediately after the interview. Name of Employer Address No. Street City State Zip Type of Business: Telephone No. Supervisors Name Your Position and Duties: Date of Employment: From To Weekly Pay: Starting Ending Reason For Leaving: Name of Employer Address No. Street City State Zip Type of Business: Telephone No. Supervisors Name Your Position and Duties: Date of Employment: From To Weekly Pay: Starting Ending Reason For Leaving: Name of Employer Address No. Street City State Zip Type of Business: Telephone No. Supervisors Name Your Position and Duties: Date of Employment: From To Weekly Pay: Starting Ending Reason For Leaving: References Please give two unrelated persons who have knowledge of your work performance within the last three years such as a co-worker, professor, advisor or supervisor. A PERSONAL FRIEND OR FRIEND OF THE FAMILY IS NOT ACCEPTABLE. Name Address No. Street City State Zip Relationship: Telephone No. No. of years acquainted Name Address No. Street City State Zip Relationship: Telephone No. No. of years acquainted Please Read Carefully, Initial Each Paragraph and Sign Below I understand that lying or misrepresentations on this application (which includes writing false or misleading information, or leaving out information) will result in either immediate termination if employed or in the loss of opportunity for possible future employment. Applicant Date I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I hereby understand that Potential Employer prides itself on its ability to hire and retain great talent. Therefore, the interview process including: the details of each interview, confidential and proprietary information, salary and/or offer letters and/or discussions are confidential. To share and/or discuss this information with anyone not employed by Potential Employer would result in a breach of confidentiality which could be legally pursued by Potential Employer. I hereby authorize Potential Employer to thoroughly investigate my references, work record, education, credit, criminal records, civil records, social security number, and other matters related to my suitability for employment. Further, I authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Potential Employer, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. I hereby agree to submit to binding arbitration all disputes and claims arising out of the submission of this application .I further agree, in the event that I am hired by the company, that all disputes that cannot be resolved by informal internal resolution which might arise out of my employment with the company, whether during or after that employment, will be submitted to binding arbitration. I agree that such arbitration shall be conducted under the rules of the American Arbitration Association. This application contains the entire agreement between the parties with regard to dispute resolution, and there are no other agreements as to dispute resolution, either oral or written. I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and Potential Employer. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at option of either myself or Potential Employer, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s designated representative. By signing below, I certify that the statements above and on any attachments are true and complete as of the date given. I authorize Potential Employer or agents to investigate applicants’ background and credit worthiness as needed. The undersigned authorizes all references and credit reporting agencies and its agents to release all necessary information. Applicant’s Signature Date