Position Applied for:    Date:

Name:   Soc. Sec. No.

Address:  

Telephone:

Education   List School or Classes attended Note: If you have not graduated, list last completed grade.

Name/Address of Institution                                    Degree Received                                                Date

Reference     Give at least three references.            Do not include family members as references.

Employment Experience            List the 3 most recent positions that you have held.

Company Name        Dates             Job Title                      Description & Pay                    Reason for Leaving

Computer Experience  Include e-mail, web, Microsoft Excel, Microsoft Word, etc.

Interests, Hobbies

Civic, Community, Church       List any organization that you belong to & offices held.

Other Information          List any other information that might qualify you for this position.

Questions:

Have you ever been convicted or charged with a felony, misdemeanor, or other offense other than a minor traffic violation?

Yes or No   

 (Convictions will not necessarily bar employment.) If yes, please explain:  

Date available for work?  

What are your minimum hourly pay rate expectations?  ($ per hour)

Are you available to work from 8 am to 5 pm Monday through Saturday and later if need arises?   

Do you have transportation to work?  

Essay

In 100 words, please explain why we should hire you over the other candidates. You may include your experience, knowledge, personal attributes, or other reasons.

Signature

My signature below confirms that:

The information that I have provided is true and correct to the best of my knowledge. I authorize you to confirm any information provided, obtain employment references and personal history, reputation for honesty, ability, and responsibility and obtain a consumer report which may include a criminal background check information. I release all parties and persons from liability that may result from furnishing such information to you, as well as, from the disclosure of such information to you. Any misrepresentation, falsification, or material omission on this application may result in my failure to receive an offer of work or dismissal from employment if hired. I agree that the employment relationship may be terminated either by me or by you, with or without notice at any time. I authorize you to give out any information regarding my employment with this company, if hired, and release all parties from liability that may result from furnishing such information.

 Signature__________________________________________ Date___________

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