Application For Employment

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Personal Information

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Name
Address
In the event of an emergency, who can we contact?
Employment Desired
Type of Work Desired
Shift
Salary
 
Will You Accept Employment of
Are You 18 Years of Age or Older?
Are You Employed Now?
May We Contact Your Present Employer?

Education

Education
Name of School
Location (City, State)
Course Taken
Completed
Type of Degree or Certificate Received
 

Professional Licenses and/or Certifications

Professional Licenses and/or Certifications
Type
Organization or State Issued
Date Issued
Number
Verification
 
If your former employment references, education or military service are under a name other than indicated on front of application, please indicate below.
Name

Employment Record (list last or present position first)

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Please Indicate Availability (Be Specific)

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Availability Record

Are you available to work
Weekends?
Holidays?
Rotating Shifts?
If your availability changes, it is your responsibility to fill in an “Availability Card” indicating the changes. Such changes will be effective, then for any future employment.

Professional References

Professional References
Name
Organization
Phone
Email
 

Employment Understanding (Please Read and Sign)

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination and pre-employment drug screening, and any future physical examinations or drug screening as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform, a criminal background check and pre-employment drug screening.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.

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