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 EMPLOYMENT APPLICATION

Applications are considered for all positions without regard to race, color, religion, sex, national origin, age, marital

or veteran status, or in the presence of a non-related medical condition or handicap.

Name_______________________________________________________Date___________________

Address___________________________________________________Phone #___________________

City_____________________State_____Zip__________Social Security #_______________________

E-mail address_______________________________________________DOB_________________

Are you a citizen of the United States of America? [ ] Yes [ ] No

Have you ever been convicted of a felony? [ ] Yes [ ] No If yes, please describe the circumstances:

___________________________________________________________________________________

Have you applied here before? [ ] Yes [ ] No When?______Position applied for?_________________

Start When_______________ [ ] Full time [ ] Part time [ ] Temporary [ ] Other__________________

If selected for employment, are you willing to submit to a pre-employment drug screening test?

[ ] Yes [ ] No Desired Wage/Salary$_________________

EMPLOYMENT EXPERIENCE; Start with your present job or last job. Include military assignments and other

volunteer activities. Exclude organizational names which indicate race, color, religion, sex, or national origin

  • Employer __________________________________________________________________________

    Address___________________________________City________________State_____Zip__________

    Phone #________________Supervisors’ Name_____________________________________________

    Job Title______________________Reason for leaving_______________________________________

    Dates of Employment: From_________To__________Salary or Hourly rate______________________

  • Employer __________________________________________________________________________

    Address___________________________________City________________State_____Zip__________

    Phone #________________Supervisors’ Name_____________________________________________

    Job Title______________________Reason for leaving_______________________________________

    Dates of Employment: From_________To__________Salary or Hourly rate_____________________

  • Employer __________________________________________________________________________

    Address___________________________________City________________State_____Zip__________

    Phone #________________Supervisors’ Name_____________________________________________

    Job Title______________________Reason for leaving_______________________________________

    Dates of Employment: From_________To__________Salary or Hourly rate______________________

    EMPLOYMENT APPLICATION PART 2
    EDUCATION

    Schools/Collages Attended: # Years Year Grad. Degree

    ____________________________________________________ _______ _______ ___________

    ____________________________________________________ _______ _______ ___________

    ____________________________________________________ _______ _______ ___________

    Describe any special qualifications for this job:

    ___________________________________________________________________________________

    ___________________________________________________________________________________

    ___________________________________________________________________________________

    References:

    1.__________________________________________________________________________________________

    2.__________________________________________________________________________________________

    3.__________________________________________________________________________________________

    Drivers License #_______________________________State__________Expiration_______________

    Are you a veteran of the U.S. Military service? [ ] Yes [ ] No

    I CERTIFY that answers given herein are true and complete to the best of my knowledge. I authorize

    investigations of all statements contained in this application for employment as may be necessary in arriving at

    an employment decision. I understand that this application is not intended to be a contract of employment. In

    the event of employment, I understand that false or misleading information given on my application or

    interview may result in termination.

    Signature___________________________________________________Date_____________________

    For Personnel Department only

    Remarks____________________________________________________________________________

    ___________________________________________________________________________________

    __________________________________________Interview report by__________________________

    Accurate Credit Bureau fax 626 398-0642

    I wish to order [ ] Credit Report [ ] DMV Records [ ] Reference Verification [ ]Criminal Records