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Step
1
of 4
Application for Employment
Equal access to programs, services and employment opportunities is available to all persons without regard to age, ancestry, citizenship, status, color, physical or mental disability, genetic information, marital status, military status, national origin, race religion, sex(including pregnancy), sexual orientation, or any other basis protected by federal, state, and /or local law. In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include making a change to the application process; providing written materials in an alternate formate such as braille, large print, or audio recording; using sign language interpreter; using specialized equipment; or modifying testing conditions.
Date
*
Name
*
First
Last
Address
*
Address Line 1
City
Illinois
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
*
Position(s) Applied for
Referral Source
e.g., Walk-In, Job Posting, COmpany's Website, etc.
If necessary, best time to call you is...
AM or PM
May we contact you at work?
YES
NO
If yes, what is the number?
If yes, best time to call you is...
AM or PM
If you are under 18 and it is required, can you furnish a work permit?
YES
NO
N/A
If no, please explain:
Have you ever submitted an application here before?
YES
NO
If YES, give date
If YES, position
Have you ever been employed here before?
YES
NO
If YES, from
If YES, to
Is this application a request for reemployment following an extended military leave of absence from this company?
YES
NO
Are you lawfully authorized to work in the United States?
YES
NO
Date available for work
What is your desired salary range or hourly rate of pay?
$_________________________________________Per__________________________________________
Type of employment desired:
Full-Time
Part-Time
Educational Co-Op
Seasonal
Temporary
Will you relocate if the job requires it?
YES
NO
Will you travel if job requires it?
YES
NO
If they have been explained to you, are you able to meet the attendance requirements of the postions?
YES
NO
N/A
Will you work overtime if required?
YES
NO
If NO, please explain:
Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodations)?
YES
NO
Need more information about the job's "essential functions" to respond.
This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodations, or whether accommodation is necessary. These issues may be readdressed at a later stage to the extent permitted by law.
Driver's License number required if driving may be required in the job for which you are applying: (State/Number)
Have you ever been bonded?
YES
NO
Have you entered into an agreement with any former employer or other party (such as a non competition agreement) that might, in any way, restrict your ability to work for our company?
YES
NO
If YES, explain please:
Next
Employment History
Starting with your most recent employer, provide the following information. You may include any verified work performed on a volunteer basis.
JOB #1
Employer
Phone
Address
Address Line 1
City
Illinois
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Starting job title/final job title
Dates employed from
Dates employed to
Immediate supervisor and title (most recent position held)
May we contact for a reference?
YES
NO
Later
Their Email
Why did you leave?
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?
JOB #2
Employer
Phone
Address
Address Line 1
City
Illinois
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Starting job title/final job title
Dates employed from
Dates employed to
Immediate supervisor and title (most recent position held)
May we contact for a reference?
YES
NO
Later
Their Email
Why did you leave?
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked lest about the position?
JOB #3
Employer
Phone
Address
Address Line 1
City
Illinois
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Starting job title/final job title
Dates employed from
Dates employed to
Immediate supervisor and title (most recent position held)
May we contact for a reference?
YES
NO
Later
Their Email
Why did you leave?
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked lest about the position?
Explain any gaps in your employment, other than those du to personal illness, injury or disability.
If not addressed on previous page, have you ever been fired or asked to resign from a job?
YES
NO
If YES, please explain:
Previous
Next
Skills and Qualifications
Summarize any special training, skills languages, licenses, and/or certificates that may assist you in performing the position for which you are applying:
Computer Skills
Word Processing
Spreadsheet
Presentation
E-mail
Internet
Other Computer Skills not listed that may assist you in performing the position for which you are applying :
Educational Background
Starting with your most recent school attended, provide the following information.
School #1
School #1 (include City & State)
Years completed
1
2
3
4
Completed
Diploma
GED
Degree
Certification
Other
Degree Type
GPA/MAJOR/MINOR
School #2
School #2 (include City & State)
Years completed
1
2
3
4
Completed
Diploma
GED
Degree
Certification
Other
Degree Type
GPA/MAJOR/MINOR
School #3
School #3 (include City & State)
Years completed
1
2
3
4
Completed
Diploma
GED
Degree
Certification
Other
Degree Type
GPA/MAJOR/MINOR
School #4
School #4 (include City & State)
Years completed
1
2
3
4
Completed
Diploma
GED
Degree
Certification
Other
Degree Type
GPA/MAJOR/MINOR
References
List names and phone numbers of three business/work references who are NOT related to you and are NOT previous supervisors. If not applicable, list three school or personal references who are NOT related to you.
Reference #1 Name
*
First
Last
Phone
Email
Title
Years known
Reference #2 Name
*
First
Last
Phone
Email
Title
Years known
Reference #3 Name
*
First
Last
Phone
Email
Title
Years known
Previous
Next
Related Information
Wen answering these questions, please exclude any information that would reveal age, ancestry, citizenship status, color, physical or mental disability, genetic information, marital status, military status, national origin, race, religion, sex (including pregnancy), or other similarly protected status.
To what job-related organizations (professional, trade, etc.) do you belong?
List special accomplishments, publications, awards, etc.
List any relevant volunteer work.
Is there any other job related information you want us to know about you?
Applicant Statement
I certify that all information I have provided in order to secure work with this employer is true, complete, and correct. I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law. I understand that this application remains current for only 60 days. After that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete a 1-9 Form in this regard. I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer's affiliate(s) and third parties engaged by the employer to perform services for the employer. Any personal information shared with an affiliate or third party is to be used solely to perform the services requested by the employer. This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her age, ancestry, citizenship status, color, physical or mental disability, genetic information, marital status, military status, national origin, race, religion, sex (including pregnancy), sexual orientation, or any other protected status under applicable federal, state, or local law. Please be advised pursuant to Illinois law, applicants are not obligated to disclose expunged juvenile records of adjudication, arrest, or conviction. I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATMENT
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
Date
*
DIGITAL SIGNATURE OF APPLICANT
*
Email
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