Application Form For Employment Page 2
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1
2Employment History
List your last three (3) employers, if applicable, assignments or volunteer activities, starting with the most recent, including military
experience. Explain any gaps in employment in comments section below.
EMPLOYER
TELEPHONE
DATES EMPLOYED
Summarize the nature of the work
(
)
-
performed and job responsibilities
FROM
TO
ADDRESS
CITY
STATE
ZIP CODE
JOB TITLE
HOURLY RATE/SALARY STARTING
$
PER
IMMEDIATE SUPERVISOR AND TITLE
REASON FOR LEAVING
HOURLY RATE/SALARY FINAL
$
PER
MAY WE CONTACT FOR REFERENCE?
YES
NO
EMPLOYER
TELEPHONE
DATES EMPLOYED
Summarize the nature of the work
(
)
-
FROM
TO
performed and job responsibilities
ADDRESS
CITY
STATE
ZIP CODE
JOB TITLE
HOURLY RATE/SALARY STARTING
$
PER
IMMEDIATE SUPERVISOR AND TITLE
REASON FOR LEAVING
HOURLY RATE/SALARY FINAL
$
PER
MAY WE CONTACT FOR REFERENCE?
YES
NO
EMPLOYER
TELEPHONE
DATES EMPLOYED
Summarize the nature of the work
(
)
-
FROM
TO
performed and job responsibilities
ADDRESS
CITY
STATE
ZIP CODE
JOB TITLE
HOURLY RATE/SALARY STARTING
$
PER
IMMEDIATE SUPERVISOR AND TITLE
REASON FOR LEAVING
HOURLY RATE/SALARY FINAL
$
PER
MAY WE CONTACT FOR REFERENCE?
YES
NO
_______________________________________________
Comments (including explanation of any gaps in employment)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________
List any additional information you would like us to consider.
__________________________________________________________________________________________
__________________________________________________________________________________________
References
List name and telephone number of TWO ADULT business/work references who are not related to you. If not applicable, list three school or personal references
who are not related to you.
NAME
TELEPHONE
RELATIONSHIP
YEARS KNOWN
(
)
_
(
)
_
(
)
_
It is understood and agreed that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the service of the
employer if I have been employed. Furthermore, I understand that as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without
cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary. I give the employer right to investigate all
references and to secure additional information about me, if job related. I hereby release the employer from liability and its representatives for seeking such information and all other persons,
corporations and organizations for furnishing such information. This company is an equal opportunity employer. No questions on this application is used for the purpose of limiting or excluding
any applicant’s consideration for employment on a basis prohibited by local, state or federal law. This application is current for one (1) year. At this conclusion of this time, if I have not heard
from the employer and still wish to be considered for employment, it will be necessary for me to fill out a new application.
SIGNATURE OF APPLICANT _____________________________________________ DATE ______/______/_______
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