Job Application

Application for Employment

An Equal Opportunity Employer

We do not discriminate on the basis of race, religion, national origin, color, sex, age, veteran status, or disability. It is our intention that all qualified applicants be given equal opportunity and that selection decisions are based on job-related factors.


Present Address
Would you prefer
Are there any restrictions to the hours you would be available for work?
Were you previously employed by this organization?
If hired, on what date would you be available for work?

*If you are applying for a job with minimum age requirements, you may be required to submit proof of age.

For jobs with minimum age requirements please fill in your Date of birth:
If hired, can you furnish proof you are eligible to work in the United States?(Required)
Have you ever been convicted of a felony?
Have you previously applied here?

Personal References 1 (not former employers, or relatives)

Name and Occupation

Personal References 2

Name and Occupation

Participation in Professional, Civic or Volunteer Organizations 1

Participation in Professional, Civic or Volunteer Organizations 2

Participation in Professional, Civic or Volunteer Organizations 3

Education Record 1

Education Record 2


Work History 1 (Begin with the most recent, list all past employers, including any pertinent military experience.)

Date started
Date Finished
Rate of Pay

Work History 2

Date started
Date finished
Rate of Pay

Work History 3

Date started
Date finished
Rate of Pay


May we contact your current employer for references?
Do you smoke?


Affidavit: I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree that the company shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this questionnaire. I also authorize the companies, schools or persons named above to give any information regarding my employment, character and qualifications. I hereby release said companies, schools or persons from all liability for any damage for issuing this information. I understand that there is no express or implied contract of employment and that if employed I have been hired at the will of the employer and that my employment may be terminated at will, at any time; and with or without cause the employer’s only obligation being to pay salary or wages due and owing at the time of termination. Finally, I understand that all company property must be returned and my indebtedness to the company must be paid before my termination. I authorize the company to deduct from the final paycheck(s) all monies due and owing to the company.