FOR OFFICIAL USE ONLY Application Application Dept. Occupation Clock Rate EMPLOYMENT APPLICATION Date We are an Equal Opportunity Employer. It is our policy to abide by all Federal, State, and local laws concerning discrimination in employment. No question in this application is intended to elicit information in violation of any such law nor will any information obtained in response to any question be used in violation of any such law. Last Name First Middle Social Security No. Street Address Home Phone City State Zip How Long at Present Address? Position Applying For Wages Expected Were you previously employed by this Department Yes, Dates No Name Relationship List any relatives or friends working for this organization In case of accident notify Phone EDUCATION HIGH SCHOOL Name and Location of School Course of Study No. of Years Completed Did You Graduate Yes No Yes No Yes No Yes No Diploma or Degree TRADE OR BUSINESS SCHOOL COLLEGE OR UNIVERSITY GRADUATE SCHOOL Have you served an apprenticeship? Yes Where did you serve? No When did you serve? Type or Trade How Long? Mechanical and/or Technical Experience (Describe any and all qualifications): Have you been convicted of a crime in the past 10 years, excluding misdemeanors and summary offenses, which has not been annulled, expunged, or sealed by a court? (A Conviction record will not necessarily be a bar to employment Yes No If ''Yes,'' please describe in full detail: Can you verify your legaI rights to work in the U.S. by providing a birth certificate, proof of U.S. Citizenship, or by some other means? Yes No 2001 © American LegalNet, Inc. Continued on Other Side Are you able to perform the job(s) for which you are applying? Yes No EXPERIENCE -List Present and Former Employers for last 10 years beginning with most recent NAME AND ADDRESS OF COMPANY SUPERVISOR DESCRIBE YOUR WORK DATE LAST WAGES STARTED LEFT REASON FOR LEAVING May we contact the above employers? Additional Remarks: Yes No APPLICANT'S CERTIFICATION - Please read carefully before signing. I certify that, to the best of my knowledge and belief, the answers given by me to the foregoing questions and the statements made by me in this application are correct and complete. I understand that misrepresentation or omission of facts in this application may lead to my discharge. If employed, I understand and agree that such employment may be terminated at any time, without prior notice, and that my employment will not be governed by any expressed or implied contract but is at-will. Applicant's Signature Date Interview? DO NOT WRITE BELOW - FOR COMPANY USE ONLY No Yes Date Hour Results of Interview: Acceptable for Employment? Yes No Starting Rate Starting Date Shift Interviewed By Date Approved By Date 2001 © American LegalNet, Inc.
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