Employment Application

Please type in all information.

Personal Information

Today's date:

Social Security Number:   [Please make up a number.]

Last Name:        First Name:        Middle Name:

Home Address:     Apt #:

City:        State:        Zip:

Home Phone:        Cell Phone:

Date of Birth (xx-xx-xxxx):        Age:       

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Education - School Most Recently Attended

Name     Street Address

City     State     Zip

Country     Phone number    

Last grade completed     Graduated? Yes No    Date graduated

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Availability

Total hours available per week     Date available     Can you work overtime? Yes No

Days and Hours Available

	SUN	MON	TUE	WED	THUR	FRI	SAT
From
To

Total hours desired

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Legal

Are you a U.S. citizen?

Yes No

If no, do you have a legal right and necessary documents to work in the U.S.?

Yes No

(Identity and employment of all new hires will be verified as required by the Immigration and Control Act of 1968.)

Were you ever discharged by any employer?

Yes No

If yes, give the name of the company(ies). Separate names with commas.



Reasons for discharge.



Have you ever been convicted of a crime, excluding minor traffic violations,
or are you currently subject to deferred adjudication? Yes No

If yes, please explain the offense and final disposition, and state of occurence.

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Employment History

List employment starting with your most recent position.
Please indicate if you were employed under a different name.

May we contact your present employer? Yes No

Employer:        Address:

City:        State:        Zip: Phone:

Position held:        Supervisor:       

Major duties:

Salary and Wages: Start     Final     

Start date (mm/yy):        End date (mm/yy):       

Reason for leaving:       

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Employer:        Address:

City:        State:        Zip: Phone:

Position held:        Supervisor:       

Major duties:

Salary and Wages: Start     Final     

Start date (mm/yy):        End date (mm/yy):       

Reason for leaving:       

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Employer:        Address:

City:        State:        Zip: Phone:

Position held:        Supervisor:       

Major duties:

Salary and Wages: Start     Final     

Start date (mm/yy):        End date (mm/yy):       

Reason for leaving:       

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References

Do not list relatives or previous employers.

Last Name:        First Name:       

Address:     City:

State:        Zip:

Phone:        Years Known:

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Last Name:        First Name:       

Address:     City:

State:        Zip:

Phone:        Years Known:

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Last Name:        First Name:       

Address:     City:

State:        Zip:

Phone:        Years Known:

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When you are finished, please ask your teacher to look at this form. Thanks.