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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

Desired Salary

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

 

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.