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HOURLY EMPLOYMENT APPLICATION
We are committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant or employee on the basis of race, color, religion, creed, national origin or ancestry, sex, gender identity, age, physical or mental disability, veteran or military status, genetic information, sexual orientation, marital status, or any other legally recognized protected basis under federal, state or local laws, regulations or ordinances. The information collected by this application is solely to determine suitability for employment, verify identity and maintain employment statistics on applicants.

Applicants with disabilities may be entitled to reasonable accommodation under the terms of the Americans with Disabilities Act and certain state or local laws. A reasonable accommodation is a change in the way things are normally done which will ensure an equal employment opportunity without imposing undue hardship on the Company. Please inform the Company’s personnel representative if you need assistance completing any forms or to otherwise participate in the application process.

Please provide complete information. An incomplete application may affect your consideration for employment.

PERSONAL

Last Name

First Name

Middle

Type
Address Line 1
Address Line 2
City
State/Province
Zip/Postal Code
Country
Type
Number
Extension

E-mail Address

Are you legally authorized to work in the U.S.?
Yes         No

Do you now, or will you in the future, require immigration sponsorship for work authorization (e.g., H-1B)? (If hired, verification will be required consistent with federal law.)
Yes          No

Are you at least 18 years old? (if not, you may be required to provide authorization to work.)
Yes         No

How did you hear about us?

Willing to Relocate?
Yes         No

Have you worked for this Company before?
Yes          No

If yes, list dates employed

 

From:

To:

Do you have any relatives employed by this organization?
Yes          No

If yes, give name and title:

 

POSITION INFORMATION

Desired Type of Employment

Salary Range Expected

Date Available to Start


Type of Work Desired

Work Schedule Availability

How many hours per week are you available to work?
Are you willing to work holidays and weekends?
Yes        No
Do you have a reliable method of transportation to and from work?
Yes        No
Please list desired shift availability

Monday

 Anytime     AM      PM      N/A

Tuesday
Anytime     AM      PM      N/A
Wednesday
Anytime     AM      PM      N/A
Thursday
Anytime     AM      PM      N/A
Friday
Anytime     AM      PM      N/A
Saturday
Anytime     AM      PM      N/A
Sunday
Anytime     AM      PM      N/A

 

EDUCATION
School/Institution Name
City
State/Province
Country
Did You Graduate
Degree
GPA
Start Date
End Date
Number of Years Completed
Major/Area of Study
Minor
List any work related certifications or licenses you currently possess.

 

WORK EXPERIENCE
List all employment experience for the past seven years, starting with the most recent or present employer, including US Military Service. Using a separate section for each position, describe in detail all work experience including periods of unemployment. You may include as part of your employment history any verified work performed on a volunteer basis. Resumes may not be substituted in lieu of completing the following employment information.
Name of Employer
Address
City
State/Province
Postal Code
Country
Your Job Title

Start Date

End Date

Starting Salary
Ending Salary
Supervisor's Name
Supervisor's Title
Description
Reason For Leaving
May We Contact?
Employer Phone Number

 

REFERENCES
List three professional references (other than those listed as current/former supervisor) that we may contact.
Name
Relationship
Phone
E-Mail
Name
Relationship
Phone
E-Mail
Name
Relationship
Phone
E-Mail

 

BACKGROUND INFORMATION

During the past seven years, have you ever been discharged, suspended or asked to resign from any position?
 Yes     No

If yes, please explain:

For the purposes of verifying information on this application, have you ever worked or attended school under a different name at any of the organizations you have listed?
 Yes     No

If yes, please specify name:


Before completing this section, please read the State Specific Notices below. Answering "Yes" to the question below will not automatically bar you from employment. Only those crimes which are substantially related to the position will be considered.

Criminal Background - State Specific Notices

 

California Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT. Do not identify any misdemeanor conviction for which probation has been successfully completed or otherwise discharged and the case has been dismissed by a court. Also, do not identify marijuana-related convictions entered by the court more than two (2) years ago that involve: unlawful possession of marijuana; transportation or giving away of up to 28.5 grams of marijuana, other than concentrated cannabis, or the offering to transport or give away up to 28.5 grams of marijuana, other than concentrated cannabis; possession of paraphernalia used to smoke marijuana; being in a place with knowledge that marijuana was being used; or being under the influence of marijuana. Also, do not identify any arrest or detention that did not result in a conviction or any record of a referral to, and participation in, any pretrial or post trial diversion program.

(San Francisco Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT. When answering the question, do not disclose any misdemeanor and felony convictions that occurred more than seven (7) years prior to the inquiry or: (a) arrests other than those which charges are still pending, (b) completion of any diversity program, (c) sealed or juvenile offenses, or (d) infractions that are not felonies or misdemeanors.)

(Los Angeles Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.)

 

Connecticut Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION ON AN INITIAL EMPLOYMENT APPLICATION.  You are not required to disclose the existence of any arrest, criminal charge, or conviction, the records of which have been erased under Section 46b-146, 54-76o or 54-12a of the Connecticut General Statutes.

Criminal records subject to erasure under Section 46b-146, 54-76o or 54-142a of the Connecticut General Statutes are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which a person has been found not guilty or a conviction for which a person received an absolute pardon.

Any person whose criminal records have been erased under Section 46b-146, 54-76o or 54-142a of the Connecticut General Statutes shall be deemed to have never been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear under oath.

 

District of Columbia:  DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT. Do not identify convictions or arrest records that occurred more than ten (10) years before the date of this application.

 

Georgia Applicants: Do not identify verdict or plea of guilty or nolo contendere that was discharged by the court under Georgia's First Offender Act.

 

Hawaii Applicants:  DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT. Please limit your responses to any convictions within the past ten (10) years, excluding any period of time when you were incarcerated.

Illinois Applicants:  DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE BEEN NOTIFIED OF SELECTION FOR AN INTERVIEW, OR IF NO INTERVIEW, UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.

(Chicago Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE BEEN NOTIFIED OF SELECTION FOR AN INTERVIEW, OR IF NO INTERVIEW, UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT).

 Maine Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNTIL YOU HAVE BEEN CONTACTED BY THE EMPLOYER REGARDING THE POSITON AFTER THE SUBMISSION AND REVIEW OF YOUR APPLICATION.

Maryland Applicants:
(Baltimore Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.)
(Montgomery County Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.)
(Prince George's County Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.)

Massachusetts Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT. An applicant for employment with a sealed record on file with the commissioner of probation may answer 'no record' to an inquiry about previous arrests, criminal court appearances or convictions. An applicant for employment with a sealed record on file with the commissioner of probation may answer 'no record' to an inquiry about previous arrests or criminal court appearances. In addition, any applicant for employment may answer 'no record' to any inquiry about previous arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution.

You do not have to identify first conviction for any of the following misdemeanors: drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace, or a conviction for any misdemeanor where the date of conviction or the completion of any period of incarceration was five (5) or more years ago, unless there have been subsequent convicts within those five (5) years.


Michigan Applicants: Do not identify any misdemeanor arrests, detentions or dispositions that did not result in conviction.

Minnesota Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE BEEN NOTIFIED OF SELECTION FOR AN INTERVIEW, OR IF NO INTERVIEW, UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.

Missouri Applicants:
(Columbia Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.)
(Kansas City Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE BEEN INTERVIEWED, OR IF NO INTERVIEW, UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.)

Nebraska Applicants: Do not identify a sealed juvenile record of arrest, custody, complaint, disposition, diversion, adjudication or sentence.

Nevada Applicants: You must disclose all felony convictions, but may limit disclosure of misdemeanor convictions to those that occurred within the last seven (7) years and resulted in imprisonment. The discharge and dismissal of certain first time drug offenses, after the accused has completed probation and any required treatment or educational programs, does not constitute a “conviction” for purposes of employment.

New Jersey Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNTIL AFTER BEING INTERVIEWED IN PERSON OR BY TELEPHONE.

New Mexico Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNTIL YOU HAVE BEEN CONTACTED BY THE EMPLOYER REGARDING THE POSITON AFTER THE SUBMISSION AND REVIEW OF YOUR APPLICATION.

New York Applicants: You may answer "no record" concerning any criminal proceeding that terminated in your favor, per section 160.50 of the New York Criminal Procedure Law; any criminal proceeding that terminated in a "youthful offender adjudication," as defined in section 720.35 of the New York Criminal Procedure Law; any conviction for a "violation" that already has been sealed by the court, per section 160.55 of the New York Criminal Procedure Law; and any conviction that was sealed pursuant to section 160.58 of the New York Criminal Procedure Law in connection with the licensing, employment or providing of credit or insurance.
(Buffalo Applicants: YOU ARE NOT REQUIRED TO RESPOND UNTIL AFTER BEING INTERVIEWED IN PERSON OR BY TELEPHONE.)
(New York City Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.)
(Rochester Applicants: YOU ARE NOT REQUIRED TO RESPOND UNTIL AFTER BEING INTERVIEWED IN PERSON OR BY TELEPHONE.)

Ohio Applicants: Do not report any arrest or conviction for a minor misdemeanor drug violation as defined under Ohio Rev. Code § 2925.11.

Oregon Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNTIL AFTER BEING INTERVIEWED IN PERSON OR BY TELEPHONE, OR IF NO INTERVIEW, UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.
(Portland Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.)

Pennsylvania Applicants: Do not identify convictions for summary offenses.
(Philadelphia Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.)

Rhode Island Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.

Texas Applicants:
(Austin Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT.)

Vermont Applicants:
DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNTIL YOU ARE BEING INTERVIEWED, OR IF NO INTERVIEW, UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT

Washington Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNLESS YOU HAVE BEEN NOTIFIED OF SELECTION FOR AN INTERVIEW, OR IF NO INTERVIEW, UNLESS YOU HAVE RECEIVED A CONDITIONAL OFFER OF EMPLOYMENT. Do not identify any conviction entered by the court more than ten (10) years ago unless some period of incarceration resulting from that conviction took place within the last ten (10) years.
(Seattle Applicants: DO NOT ANSWER THE CRIMINAL HISTORY QUESTION UNTIL AFTER COMPLETING AN INITIAL SCREEN.)

Have you ever been convicted of a crime that has not been expunged, sealed, pardoned, annulled, statutorily eradicated or dismissed upon condition of probation? You are not required to disclose sealed or expunged records of conviction or arrest, or expunged juvenile records of conviction or arrest.

Yes  No Record

If you answered "Yes," to the previous question, please provide county and state of conviction and the date and nature of the offense, along with any sentencing information.

 

PLEASE READ EACH PARAGRAPH CAREFULLY BEFORE SIGNING
I have disclosed all information that is relevant and should be considered applicable to my candidacy for employment.

I understand, where permissible under applicable state and local law, I may be subject to a pre-employment drug test after receiving a conditional offer of employment, and must receive a negative result for illegal drug use before being permitted to commence work with Company. I understand, where permissible under applicable state and local law, I may be subject to a pre-employment medical examination after receiving a conditional offer of employment, and must meet the qualifications for the position, with or without reasonable accommodation, before being permitted to commence work with Company. I understand, where permissible under applicable state and local law, I may be subject to a pre-employment background check after receiving a conditional offer of employment to investigate my criminal background and other matters related to my suitability for employment.
Initials

I hereby certify that the information given by me is true in all respects. I authorize Company and its representatives to contact my prior employers and all others (with the exception of my current employer, only if I have marked "May we contact your present employer" on this application as "No") for the purpose of verification of the information I have supplied and release same from any liability resulting from the information released. I authorize employers, schools and other persons named on this application to provide any information or transcripts requested.
Initials

I understand employment with Company is also contingent on my providing sufficient documentation necessary to establish my identity and eligibility to work in the United States.

If employed, I understand that as a condition of employment that I may be required to agree to and sign a non-solicitation, non-disclosure, and/or other similar agreements. I also agree to notify the organization during the pre-employment process of any non-solicitation, non-disclosure, and/or other similar agreements that I may have already signed with current and former employers.

I expressly understand and agree that, if employed, my employment, having no specified term, is based upon mutual consent and may be terminated at-will, with or without cause, by either party (Company or me) without prior notice to the other, unless otherwise prohibited by law.

I understand that no representation, whether oral or written, by any representative or agent of Company, at any time, can constitute an implied or express contract of employment. I further understand no representative or agent of Company has the authority to enter into an agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other terms or condition of employment other than in a document signed by an authorized representative.

I understand that the technical processing and transmission of the application, including my personal information, may involve (a) transmissions over various networks, including the transfer of this information to the United States and/or other countries for storage, processing and use by Company, its affiliates, and their agents; and (b) changes to conform and adapt to technical requirements of connecting networks and devices. Accordingly, I agree to permit such parties to make such transmissions and changes, and hereby provide the necessary consent for the same.
Initials

State Specific Notices

Massachusetts Applicants: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liabilities.

Maryland Applicants: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A POLYGRAPH EXAMINATION OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

I certify that all of the above information is true and complete, and I understand that any falsification or omission of information may disqualify me from further consideration for employment or, if hired, may result in termination regardless of the time elapsed before discovery.

Note: An offer of employment is conditioned upon complying with Company's requirements including, but not limited to, signing a consent to conduct a background investigation.

I AGREE, AND IT IS MY INTENT, TO SIGN THIS EMPLOYMENT APPLICATION BY CHECKING THE "I ACCEPT" BOX BELOW AND BY ELECTRONICALLY SUBMITTING THIS DOCUMENT TO COMPANY, I UNDERSTAND THAT MY SIGNING AND SUBMITTING THIS DOCUMENT IN THIS FASHION IS THE LEGAL EQUIVALENT OF HAVING PLACED MY HANDWRITTEN SIGNATURE ON THE SUBMITTED DOCUMENT.
 I ACCEPT
By checking the box above you are applying your signature and you agree to this Applicant Statement.