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    APPLICATION FOR EMPLOYMENT

    To the Applicant: We appreciate your interest in our company and assure you that we are interested in your qualifications.  A clear understanding of your background and work history will aid us in seeking to place you in a position which, in our judgment, best meets your qualifications.  You may complete this application now or return the completed application at a later time.  You may show this application to any person of your choice.

    We are an equal opportunity employer and will not unlawfully discriminate on the basis of race, color, sex, religion, national origin, age, marital or veteran status, the presence of a medical condition or disability, height, weight or any other protected status.

    PERSONAL

    Name:

    (Last)(First)(Middle)

    Date of Application:

    Address:(Street)(City)(State)(ZIP)

    Phone #:Cell #: Email:

    Are you 18 years or older?Are you a U.S. citizen? (not applicable in California)

    Are you authorized to work in the United States?  

    Have you been previously employed here?   If yes, date(s)  

    Supervisor Name(s)  

    Have you filed an application before?   If yes, date(s)  

    Do you have any friends or relatives working here   If so, whom?  

    EMPLOYMENT DESIRED

    Position(s) applied for:Date Available:

    Type of work sought:   Salary desired :

    Are you available to work (check all that apply)  

    List any days you are not available to work:  

    List any special training, skills, qualifications or other experiences that relate to the position(s) applied for.  

    PROFESSIONAL LICENSES/CERTIFICATES

    Type of License Held

    License Number

    Expiration

    1

    2

    3

    Employers must make accommodations to disabled applicants and employees where the accommodation does not impose an undue hardship on the employer. Under Michigan law only, disabled employees and applicants may request an accommodation of their disability by notifying the firm in writing of the need for accommodation within 182 days of the date the disabled individual knows or should know that an accommodation is needed. This requirement does not apply to an individual's right under the Americans with Disabilities Act. Failure to properly notify the firm may preclude any claim that the employer failed to accommodate the disabled individual.

    EMPLOYMENT EXPERIENCE: (List current or most recent job first)

    1

    Employer  

    Dates

    Work Performed

    Address  

    From

    To

    CityStateZip

     

    Phone Number (with area code)

    Hourly Rate/Salary

     

    Job Title

    Starting

    Final

     

    Supervisor

     

    Reason for Leaving

    May we contact?

    2

    Employer  

    Dates

    Work Performed

    Address  

    From

    To

    CityStateZip

     

    Phone Number (with area code)

    Hourly Rate/Salary

     

    Job Title

    Starting

    Final

     

    Supervisor

     

    Reason for Leaving

    May we contact?

    3

    Employer  

    Dates

    Work Performed

    Address  

    From

    To

    CityStateZip

     

    Phone Number (with area code)

    Hourly Rate/Salary

     

    Job Title

    Starting

    Final

     

    Supervisor

     

    Reason for Leaving

    May we contact?

    List any other positions held on a separate sheet

    EDUCATION

    Name / Location

    Years Completed

    Diploma / Degree

    Courses of Study>

    Elementary

    High School

    College

    Graduate

    Vocational/Training

    REFERENCES (Do not include relatives or former employers)

     

    Name

    Address

    Phone

    Number

    Years Acquainted

    1

    2

    3

    MILITARY SERVICE RECORD

    Have you had any experience in the Armed Forces of the United States or in a State National Guard?

    If yes, what branch ?  Rank at DischargeDate of Discharge

    Special/technical training  

    ADDITIONAL INFORMATION

    Have you ever been convicted of a crime? (A conviction may not disqualify you, but false statements will.)

    If so, where, when and nature of offense:

    Do you have a valid driver's license?  License NoState

    List professional trade, business or civic activities and offices held excluding groups the name or character of which indicate race, color, religion, sex, national origin, disability, marital or veteran status, height, weight or age

    State any additional information that you feel may be helpful to us in considering your application.

    AUTHORIZATION AND UNDERSTANDING :

    Upon the signing of this application, I represent that all of the information now or hereafter given by me in support of my application is true and complete. I authorize you to verify any of the information concerning my background, including but not limited to, my employment, driving record, education, criminal history, or medical history (post-offer only), with the appropriate individuals, companies, institutions or agencies, and I authorize them to release such information as you require, including my prior disciplinary employment record, without any obligation to give me written notice of such disclosure. I also authorize you to release any information requested by any of my prospective or subsequent employers without any obligation to give me written notice of such disclosure. I hereby release you and them from any liability whatsoever as a result of any such inquiries and disclosures and this release from liability does not waive or prohibit an individual from filing a charge of discrimination under the laws enforced by the EEOC. I agree that any false information in support of my application may subject me to discharge at any time during the period of my employment.

    I agree that either party may terminate the employment relationship, with or without cause, at any time, and I further agree that this arrangement may only be altered in writing directed to me personally and signed by the president of the firm. I agree that I shall be bound by the other rules, policies, regulations and terms and conditions of employment of the firm as they are from time to time changed, and no additional obligations can be imposed on the firm except those which have been acknowledged in writing, by the president or his designated representatives.

    I agree that any action or suit against the firm, its agents or employees, arising out of my employment or termination of employment, including, but not limited to, claims arising under State and Federal law, but not Federal civil rights statutes containing a separate limitations period, must be brought within 180 days of the event giving rise to the claims or be forever barred unless the applicable statute of limitations period is shorter than 180 days in which case I will continue to be bound by that shorter limitations period. I waive any limitation periods to the contrary. I further agree that if I should bring any non-statutory action or claim arising out of my employment against the firm, in which the firm prevails, I will pay to the firm any and all such costs incurred by the firm in defense of said claims or actions, including attorney fees. I further agree that my employment is conditional until such time as the results of my post-offer physical (if such physical is required) are known.

    Date  Signature  

    FOR INTERVIEWER'S USE

    Interviewed byDate

    Comments  

     

    Interviewed byDate

    Comments  

     

    Interviewed byDate

    Comments  

     

    HIRED :  Starting DateDepartmentJob Title

    Comments

    APPROVED

    Name Title Date

    Name Title Date

    Name Title Date