Application for Employment

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, disability, or any other legally protected status.

Position(s) Applied For:

How did you learn about us? Advertisement Friend Walk-In Employment Agency Relative Other

Last Name: 

First Name: 

Middle Name: 

Street Address: 

City:    State:    Zip: 

Telephone Number: 

If you are under 18 years of age, can you provide required proof of your eligibility to work?  Yes No

Have you ever filed an application with us before? Yes No   If yes, give date: 

Have you ever been employed with us before? Yes No   If yes, give date: 

Are you currently employed? Yes No

May we contact your present employer? Yes No

Are you legally authorized to work in the United States? Yes No
Proof of citizenship or immigration status will be required upon employment.

On what date would you be available for work? 

Are you available to work:  Full Time Part Time Shift Work Temporary

If part time, what days and hours are you available to work?

Are you currently on "lay-off" status and subject to recall? Yes No

Can you travel if a job requires it? Yes No

Employment Experience

Start with your present or last job.  Include any job-related military service assignments and volunteer activities.  You may exclude organizations which indicate race, color, religion, gender, national origin, handicap, or other protected status.

Special Skills and Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.  If job-related, indicate any foreign language proficiency.

Minimum Salary Required: 

Education

Elementary School
School name and location: 

Number of years completed: 

Diploma/Degree: 

High School
School name and location: 

Number of years completed: 

Diploma/Degree: 

Undergraduate College/University
School name and location: 

Number of years completed: 

Diploma/Degree: 

Graduate/Professional
School name and location: 

Number of years completed: 

Diploma/Degree: 

Describe any specialized training, apprenticeship, skills, and extra-curricular activities:

Describe any honors you have received:

State any additional information you feel may be helpful to us in considering your application:

List any professional, trade, business or civic activities and offices held.
You may exclude organizations which indicate race, color, religion, gender, national origin, handicap, or other protected status.

Have you ever had any job-related training in the United States military?  Yes No

If yes, please describe:

If you are applying for a specific position, and have been provided a job description:

Can you perform the described functions of the job, with or without reasonable accommodations? Yes No

References

Give name, address, and telephone number of three references who are not related to you and are not previous employers:

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge.  I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days.  Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is "at will," which means that the Employee may resign at any time and the Employer may discharge Employee without prior notice at any time, and with or without cause.  It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.  I understand, also, that I am required to abide by all rules and regulations of the employer.

By filling out the below signature text box, you are giving an electronic signature which is equal to a real signature on our employment application.

Signature:

Date:

Release Authorization

In connection with my application for employment, I understand that an investigative consumer report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment.  I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private resources about my: worker's compensation injuries, driving record, criminal history, education, credentials, credit, and references.

Medical and workers' compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws.  According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer reporting agency.  If so, I will be notified and given the name and address of the agency or the source which provided the information.  I acknowledge that a telephonic facsimile (FAX), email, or photographic copy shall be as valid as the original.  This release is valid for most federal, state, and county agencies including the Minnesota Department of Labor.

This information is being verified by Single Source Services.  Any information or questions should be directed to the following address:  Single Source Services, 4 Office Park Circle, Suite 310, Birmingham, AL 35223, 205-871-3677 or 800-264-3677, fax - 205-871-9790, www.sssinc.org.

By filling out the below signature text box, you are giving an electronic signature which is equal to a real signature on our employment application.

Signature:

Date: