2011. All rights reserved. Page 1 of 3
APPLICATION FOR EMPLOYMENT
A. GENERAL INFORMATION
Last Name:
First Name:
Middle:
Date:
Previous Last Name Used:
Current Street Address:
City:
State:
Phone Number
( )
Email address:
If not a resident at current address for 2 years, give previous address &
phone number:
Lived There From:
To:
Are legally authorized to work in the United States?
Yes
No
(All persons; upon hiring, must verify eligibility to be employed in the United States.)
List states and counties of residence for the past 7 years:
Do you have an OLCC Server’s Permit?
Yes
No
If not, is there any reason why the OLCC would not grant you one? Yes No
If yes, describe fully:
Are you able to lift and carry up to 50 lbs.? Yes No
Do you have any relatives or friends working for this company?
Yes
No
If yes, give name and department:
Have you ever worked for this company before?
Yes
No If yes, when and in what capacity?
In case of an emergency, who should we
notify?
Name:
Address:
Phone Number:
( )
B. JOB INTEREST
Position Applying For:
Referred By:
Type of employment desired (check one): Full-time Part-time Temporary Summer
Shift Preference:
Salary Required:
Are you willing to work overtime? Yes No
Are you willing to work weekends? Yes No
Are you willing to travel? Yes No If yes, how often?
Date available to begin work:
Are you 21 or over?
Yes
No
C. EDUCATION
Name & Address of School Attended
Did you graduate?
List Diploma or Degree
High
School
Yes
No
Attending
College or
University
Yes No
Attending
Other
Yes
No
Attending
D. REFERENCES
Please list three persons who know of your qualifications and work abilities (do not include relatives):
2011. All rights reserved. Page 2 of 3
Name:
Email address, City & State:
Phone Number:
Occupation:
( )
( )
( )
YOUR EMPLOYMENT HISTORY
Please list below your Employment History beginning with your most recent employer. Account for all periods of time, including part-
time work, military service or unemployment. May we contact your present employer for references? Yes No
If additional space is needed, please attach supplemental information.
E. EMPLOYER NAME & ADDRESS
From
To
Supervisor:
Phone Number:
( )
Month
Year
Month
Year
Job Title:
Company Use Only
Dates Verified Position Verified
Description of Your Duties:
Reason For Leaving:
F. EMPLOYER NAME & ADDRESS
From
To
Supervisor:
Phone Number:
( )
Month
Year
Month
Year
Job Title:
Company Use Only
Dates Verified Position Verified
Description of Your Duties:
Reason For Leaving:
G. EMPLOYER NAME & ADDRESS
From
To
Supervisor:
Phone Number:
( )
Month
Year
Month
Year
Job Title:
Company Use Only
Dates Verified Position Verified
Description of Your Duties:
Reason For Leaving:
H. EMPLOYER NAME & ADDRESS
From
To
Supervisor:
Phone Number:
( )
Month
Year
Month
Year
Job Title:
Company Use Only
Dates Verified Position Verified
Description of Your Duties:
Reason For Leaving:
I. EMPLOYER NAME & ADDRESS
2011. All rights reserved. Page 3 of 3
From
To
Supervisor:
Phone Number:
( )
Month
Year
Month
Year
Job Title:
Company Use Only
Dates Verified Position Verified
Description of Your Duties:
Reason For Leaving:
J. EMPLOYER NAME & ADDRESS
From
To
Supervisor:
Phone Number:
( )
Month
Year
Month
Year
Job Title:
Description of Your Duties:
Reason For Leaving:
K. SPECIAL SKILLS & QUALIFICATIONS
Please summarize special skills, qualifications, and civic, social or professional memberships:
RELEASE AND CONSENT
I understand and certify that all information supplied in this application, and any attached resume, is complete and correct. Any false,
misleading or incomplete information furnished by me regarding this application may result in the rejection of this application or if
employed, dismissal. I understand that in consideration of my employment, I agree to conform to the rules and regulations of the
Employer, and further agree that my employment and compensation are at the will of the Employer and can be terminated, with or
without cause, and with or without notice, at any time at the option of either the Employer or myself. I understand and agree that
these terms can only be modified in writing and signed by the President. No supervisor, representative, agent, or other employee of
the Employer has now or has had in the past the authority to enter into any agreement for employment for a specified period of time,
or to make any agreement which is contrary to or in modification of the above terms, nor can any policies or practices of the Employer
either written or oral, modify the above terms.
I understand and agree to take any physical examination, and pre-employment test, including drug screening test, all such tests will be
administered in compliance with the Americans with Disabilities Act.
I understand and hereby authorize all persons, schools, companies, employers, and/or their representatives to furnish verification to
the Employer, its representatives or agents, any and all information set forth in this application and/or attached resume. In addition, I
hereby agree to hold harmless and to release from all liability all said persons, schools, companies, employers and/or their
representatives from any and all claims that I may have, or which may arise, against any and/or all of them, including the Employer, as
a result of them furnishing information to the Employer. I authorize the Employer, should they employ me, to release employment
references, if my employment becomes terminated for any reason. I also authorize the Employer to conduct credit, police, criminal and
driving record inquiries, or any other employment related inquiries in compliance with the provisions of the Fair Credit Reporting Act, 15
U.S.C. Section 1681, et. seq. I understand that the decision to hire me and my continued employment will be subject to the results of
these inquiries.
We consider applicants for all positions on the basis of qualifications and without regard to race, color, religion, gender (sex), national
origin, age, marital status, veteran status, disability, sexual orientation, use of lawful products during non-work hours and any other
legally protected status.
I understand this application will be active for employment consideration for 30 days. After 30 days, if I wish to be considered for
employment, I must contact the Employer to determine if applications are being accepted.
I have read, understand and agree with this statement.
Applicant’s Signature Date