Employer Telephone # Street Address Starting job title/final job title Immediate supervisor and title (for most recent position held) Why did you leave? Dates Employed: __________ to ______________ Hourly Salary $_________ per ________ Summarize the type of work performed and job responsibilities: May we contact for reference? If so, provide an email address. EMPLOYMENT HISTORY (START WITH MOST RECENT EMPLOYER) Application for Employment AN EQUAL ACCESS EMPLOYER Equal access to programs, services, and employment is available to all persons. Applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department. Position(s) applied for_________________________________________Date of application (MM/DD/YYYY)_________________ Name (Last/First/Middle)______________________________________________________________________________________ Address (Street/City/State/Zip)_________________________________________________________________________________ Telephone # __________________________________________ Email ___________________________________________ Referral Source (How did you hear about this position?)_____________________________________________________________ Have you ever been employed here before? If yes, give dates and positions: _____________________________________________ Is this application a request for re -employment following an extended military leave of absence from this company?_____________ (If yes, additional information may be requested.) Are you legally eligible for employment in this country?_____________________________________________________________ Date available for work: ___________________________ What is your desired salary range _____________________ Driver’s License number: (Required if driving is required in the job for which you are applying: ________________ State: ____ ___ Answering “yes,” to either part of the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, what victims were involved, rehabilitation, and position app lied for will be taken into account. Please note that all offers of employment are contingent upon an applicant passing a criminal background check and a consumer investigative report. Some applicants may also be required to pass a Child Abuse and Neglect background check, as reported by MO Dept. of Social Services or other child protective services organizations, as a condition of employment. Have you ever pleaded “guilty” or “no contest” to, or been convicted of, a crime? ________________________________________ If yes, please provide date(s) and details: __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Employer Telephone # Street Address Starting job title/final job title Immediate supervisor and title (for most recent position held) Why did you leave? SKILLS List any special training, skills, licenses, awards, and/or certificates that may assist you in performing the position for which you are applying: Description Year Awarded/Granted/Received (if applicable) Granting Organization (if applicable) EDUCATIONAL BACKGROUND Starting with your most recent school attended, provide the following information. School (include city/state) Years Completed Completed GPA Class Rank Major/Minor Diploma_______________ Degree________________ Certification____________ Other__________________ Diploma_______________ Degree________________ Certification____________ Other__________________ Diploma_______________ Degree________________ Certification____________ Other__________________ Employer Telephone # Street Address Starting job title/final job title Immediate supervisor and title (for most recent position held) Why did you leave? Dates Employed: __________ to ______________ Hourly Salary $_________ per ________ Summarize the type of work performed and job responsibilities: May we contact for reference? If so, provide an email address. EMPOYMENT HISTORY, CONTINUED Dates Employed: __________ to ______________ Hourly Salary $_________ per ________ Summarize the type of work performed and job responsibilities: May we contact for reference? If so, provide an email address. I certify that all information I have provided with this employer is true, complete, and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educa- tional institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non -defamatory information, in a lawful manner, in the em- ployment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and non question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the em- ployer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s Executive Director. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I -9 Form in this regard. This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of race, color, ancestry, national origin, gender, sexual orientation, marital status, religion, age, disability, gender identity, results of genetic testing, or service in the military, or any other protected status under applicable federal, state, or local law. Thi s Company likewise does not tolerate harassment based on sex, sexual orientation, gender identity, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status. The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly. I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immedi- ate discharge from the employer’s service, whenever it is discovered. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. Signature of Applicant________________________________________Date (MM/DD/YYYY)__________________ APPLICANT STATEMENT REFERENCES List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you. NAME Title Relationship to You Telephone Email # Years Known
