Job Application Step 1 of 5 20% Location applied for*EaganWoodburyPrior LakePosition(s) applied for* Date* MM slash DD slash YYYY How did you find out about this job?* Facebook Craigslist Employee Walk-in Relative Other Other Applicant InformationName* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*If hired, do you have a reliable means of transportation to get to work? Describe Are you at least 18 years old?* If you are under 18 years of age, can you furnish a work permit? State* Date* MM slash DD slash YYYY Are you legally eligible for employment in the U.S.? (Proof of U.S. citizenship or immigration status is required if hired.)Have you been convicted of a crime? (Massachusetts applicants should not include misdemeanor convictions; California applicants should not include marijuana-related convictions that occurred more than 2 years prior to the application date.)* Yes No If yes, state the nature of the offense and disposition of the case. Include dates and places. (NOTE: The existence of a criminal record does not constitute an automatic bar to employment.)Are you a veteran? Yes No If yes, give dates of service: From MM slash DD slash YYYY To MM slash DD slash YYYY List any special skills or training Employment InformationAre you seeking full time, part time or temporary employment?* What hours and shift(s) would you prefer to work?* List times you are not available to work?* Are you willing to work overtime?* Weekends?* Holidays?* Are you currently employed?* Have you ever worked for this organization before?* If hired, when would you be able to start?* If yes, name used:* List any friends or relatives employed by this company:Have you ever been discharged or asked to resign from any position?* Yes No If yes, please describe:*If applicable, please refer to the attached job description for the position for which you are applying. Are you able to perform all these tasks with or without reasonable accommodation?* Please describe which tasks, if any, you will need accommodation to perform, and explain what type of accommodation you will need:*Please describe: Education (circle highest level achieved)Company* Phone No. with Area Code* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Dates of Employment: From* Salary: Beginning* Ending* Job Title* Supervisor’s Name & Title* Specific reason for leaving:Company* Phone No. with Area Code* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Dates of Employment: From* Salary: Beginning* Ending* Job Title* Supervisor’s Name & Title* Specific reason for leaving:For references purposes: Have you worked for any of these organizations or attended school under a different name? If yes, give name and organization(s)May we contact the employers listed above?* Yes No If not, list the employers you do not wish us to contact and why Education (circle highest level achieved)(please read carefully, then sign and date below) I certify that I have personally completed this application. I declare that the information provided in this employment application is true and complete and I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification form my dismissal from employment if discovered at a later date. I agree to immediately notify this company if I should be convicted of a crime while my job application is pending or during my employment, if hired. I authorize this company to make an investigation of all information contained in this employment application and I release from liability all companies and corporations supplying such information. I understand any false answers, statements, or implications made by me on this application or other required documents shall be considered sufficient cause for denial of employment or discharge. I specifically authorize and direct my current and former employers to supply employment-related information to this company and do hereby release my current and former employers from liability for providing information to this company. Upon termination of my employment for whatever reason, I release this company from all liability for supplying any information concerning my employment to any potential employer. I authorize this company, if applicable, to request a copy of my credit report, motor vehicle driving record, and any other investigative report deemed necessary through various third party sources. As required by law, upon request within a reasonable period of time, I will be notified as to the nature and scope of such investigations. I hereby agree to submit to any drug test required of me, whether prior to my employment or if employed by this company at any time thereafter. If requested, I will take a post-job offer physical examination and my employment, in the event I receive medical treatment for any condition, including a physical, psychological, emotional, or psychiatric condition that is job-related, I hereby authorize the limited release and exchange of such medical information relating to my condition between the treatment provider and a company-designated physician. AT-WILL EMPLOYMENT AGREEMENT I understand and agree that nothing contained in this application, or conveyed during any interview is intended to create an employment contract between the company and me. In addition, I understand and agree that if you employ me, in consideration of my employment, my employment and compensation will be at-will, for no definite period of time, and may be terminated at any time, for any reason, or for no reason at all. I understand that only the company’s President is authorized to change the employment-atwill status and such a change can only be done in writing. I have read, understand, and agree to the above.SignatureName (please print) First MASSACHUSETTS EMPLOYMENT ONLY: An application for employment with a sealed record on file with the Commissioner of Probation may answer “no record” with respect to any inquiry herein relative to prior arrests, criminal court appearances, or convictions. In addition, any applicant for employment may answer “no record” with respect to any inquiry relative to prior arrests, court appearances, and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the Superior Court for criminal prosecution. MASSACHUSETTS & MARYLAND EMPLOYMENT ONLY: An employer may not require or demand, as a condition of employment, prospective employment, or continued employment, that an individual submit to or take a lie detector or similar test. An employer who violates this law is guilty of a misdemeanor and/or subject to criminal penalties and civil liabilities.
