Employment Application Form Page 2
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1
2Please list name, address, and phone number of
Rate of Pay
Immediate Supervisor
FROM
TO
previous employers with most recent employer
first. Periods of unemployment should be included.
Job title ____________________________
Employer name, address and phone number
Duties
Reason for leaving _________________________________________________________________________________________
Job title
Employer name, address and phone number
Duties
Reason for leaving _________________________________________________________________________________________
Job title
Employer name, address and phone number
Duties
Reason for leaving
May we run an employment check from the employers listed above?
Yes
No
Has notice been given to present employer?
Yes
No
Is any additional information relative to change in name necessary to check your work history?
Yes
No
If yes, please explain
Please list references to contact who are acquainted with your work history.
Name
Title/Occupation
Nature of Acquaintance
Phone Number
1.
2.
3.
Please include any other information you think would be helpful to us in considering you for employment, such as additional work
experience, publications, activities, accomplishments, etc. (You may exclude all information indicative of age, sex, race, religion, color,
national origin or handicap, as we are an Equal Opportunity Employer.)
I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my
knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and
may be considered justification for dismissal if discovered at a later date.
I understand that my employment can be terminated, with or without cause, at any time at the discretion of the employer or myself. I
understand that no management official of the employer other than the chief executive officer of the employer has any authority to enter into
any agreement contrary to the foregoing or to make any oral assurance or promise of continued employment to me.
I authorize persons, schools, my current employer (if applicable), and previous employers and organizations named in this application (and
accompanying resume, if any) to provide any relevant information that may be required to arrive at an employment decision.
Signature
Date
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Parent category: Business