Employment Application

All applicants must have a valid driver’s license with less than 6 points, reliable transportation, current insurance, a high school diploma or GED, and be able to pass all applicable background checks to be eligible for employment.

Name

First, Last**

Maiden Name

Social Security Number

(please include at least your last 4 digits!)**

Address

Street 1*

Street 2

City*

State*

Zip*

Primary Phone

Required* --

Secondary Phone

Required*

List (Single Choice)
Required*

May we contact you by Email?*

	Yes
	No

Referred by

Additional Information

List (Single Choice)
Required*

Have you been an employee of this organization in the past?*

	Yes
	No

List (Multiple Choice)
Required*

I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States.**

Yes

List (Single Choice)

Have you ever been convicted of, or entered a plea of guilty, no contest, or had a withheld judgment to a felony?*

	Yes*
	No

"If Yes, please explain

Education History

Schools attended or special training received. List current or most recent first.

School Name

Location

(City, State)

From

Highest Grade Completed

(High School, Undergraduate, or Graduate School)

Did you graduate?

	Yes
	No

Type of Degree or diploma

School Name

Location

From

Did you graduate?

	Yes
	No

Type of Degree or Diploma

Work History

List present or most recent job first

Employer

From

Hours/Week

Job Title

Address

Street 1

Street 2

City

State

Zip

Phone

-- ext

Supervisor

List (Single Choice)

May we contact this employer?

	Yes
	No

Reason for Leaving?

Employer

From

Hours/week

Job Title

Address

Street 1

Street 2

City

State

Zip

Phone

-- ext

Supervisor

List (Single Choice)

May we contact this employer?

	Yes
	No

Reason for leaving?

Availability and Authorization

Sunday Availability	Required*
Monday Availability	Required*
Tuesday Availability	Required*
Wednesday Availability	Required*
Thursday Availability	Required*
Friday Availability	Required*
Saturday Availability	Required*
By entering my name and date below, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should an investigation disclose untruthful or misleading answers, my application may be rejected, my name removed from consideration, or my employment with this company terminated.
Signature	Your Name & Today's Date*

Desired hours

	Full time
	Part time
	PRN