PERSONAL INFORMATION
Name
Home Phone #
Cell Phone #
Present Street Address
City, ST Zip
Drivers Lic. #
Emergency Contact Name
Emergency Contact Phone #
POSITION
Position Applied For
PRIOR WORK RECORD
Most Recent Employer
Name and address
Employer Phone #
Job Title & Duties
Date Hired/Date Left		/
Pay rate when Hired/Left		/
Reason for Leaving
May we contact this employer?		Yes     No
2nd Most Recent Employer
Name and address
Employer Phone #
Job Title & Duties
Date Hired/Date Left		/
Pay rate when Hired/Left		/
Reason for Leaving
May we contact this employer?		Yes     No
3rd Most Recent Employer
Name and address
Employer Phone #
Job Title & Duties
Date Hired/Date Left		/
Pay rate when Hired/Left		/
Reason for Leaving
May we contact this employer?		Yes     No
Please provide any additional information such as special skills, training, experience equipment operation, or other qualifications you feel will be helpful to us in considering your application:
References
Reference #1
Name
Address
Telephone
Reference #2
Name
Address
Telephone
Reference #3
Name
Address
Telephone
Job Applicant's Agreement and Certificate
"I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information." "I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the company and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon the company unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that the company retains the right to do the same." "If I am offered employment, I agree to submit to a physical examination whenever requested and I understand my becoming employed and/or my continued employment are subject to the results of any physical examination related to my job duties in accordance with company policies and procedures." "I understand that if employed, policies and rules which are issued are not conditions of employment and that the employer may revise policies or procedures in whole or in part at any time." If you agree with all the above terms, please enter your name and today's date below. You agree that entering your name below is legally equivalent to your signature for the purposes of this employment application.
Your Name
Today's Date