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Our company ("Company") fully subscribes to the principles of Equal Employment Opportunity. It is our policy to provide employment, compensation, and other benefits related to employment based on qualifications, without regard to race, color, religion, national origin, age, sex, veteran status, genetic information, disability, or any other basis prohibited by federal, state or local law. In accordance with requirements of the Americans with Disabilities Act and applicable federal, state and/or local laws, it is our policy to provide reasonable accommodation upon request during the application process to applicants in order that they may be given a full and fair opportunity to be considered for employment. As an Equal Opportunity Employer, we intend to comply fully with applicable federal, state and/or local employment laws and the information requested on this application will only be used for purposes consistent with those laws. To the extent required by applicable law, The Company maintains a smoke- free workplace.
Position Applying For:
PERSONAL DATA
Salary Expectations:
Name:*
First Middle Last
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:*
Email*
If you are under 18 years of age, please specify your age:
(This information will be used only for child labor law purposes)
Are there any days, shifts or hours you will not work?**
- Yes
- No
If yes, please explain:
Will you work overtime, if required?**
- Yes
- No
*Note: It is not necessary for you to identify unavailability for work because of religious observance or practice or any other protected classification. Subsequent to any job offer, we will consider whether a reasonable accommodation can be made.
When will you be able to start work?*
MM slash DD slash YYYY
How did you learn about our company?
Have you ever applied or worked for our company before?*
- Yes
- No
If yes, provide dates:
Are you legally authorized to work in the United States?*
- Yes
- No
Will you now or in the future require sponsorship for employment visa status (e.g.,H-1B visa status)?*
- Yes
- No
Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.
DRIVING RECORD

(Answer only if driving is a requirement of the job for which you are applying).
Do you have a valid driver’s license?
- Yes
- No
State:
License Number:
Have you had any tickets?
- Yes
- No
If yes, please explain:
EDUCATION
Name, City, State of High School:
Did you graduate?
- Yes
- No
If no, Degree Credits Earned:
Type of Degree Received or Expected:
Major / Minor:
Grade Point/ Overall GPA:
Name, City, State of College or University:
Did you graduate?
- Yes
- No
If no, Degree Credits Earned:
Type of Degree Received or Expected:
Major / Minor:
Grade Point/ Overall GPA:
Name, City, State of Technical / GED:
Did you graduate?
- Yes
- No
If no, Degree Credits Earned:
Type of Degree Received or Expected:
Major / Minor:
Grade Point/ Overall GPA:
Name, City, State of Licenses / Certification / Other:
Did you graduate?
- Yes
- No
If no, Degree Credits Earned:
Type of Degree Received or Expected:
Major / Minor:
Grade Point/ Overall GPA:
EMPLOYMENT HISTORY
Please complete for all full-time or part-time employment beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis. All applicants should start with their most recent job, include military assignments and voluntary employment and provide ten (10) years of history. (A separate sheet may be attached.) You must explain any gaps in your employment history.
Company 1 Name:
Phone:
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Supervisor:
First Last
May we contact?
- Yes
- No
Dates Employed:
State job titles and describe job duties:
Reason for leaving:
Company 2 Name:
Phone:
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Supervisor:
First Last
May we contact?
- Yes
- No
Dates Employed:
State job titles and describe job duties:
Reason for leaving:
Company 3 Name:
Phone:
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Supervisor:
First Last
May we contact?
- Yes
- No
Dates Employed:
State job titles and describe job duties:
Reason for leaving:
Have you ever been discharged or asked to resign from employment?*
- Yes
- No
If yes, explain:
Did you receive any discipline in your last 12 months of active employment with your previous employer?*
- Yes
- No
If yes, explain:
Were you given a performance evaluation within the last 12 months of active employment?*
- Yes
- No
If yes, what was the range of scores used and what was your score:
Have you signed any non-competition or non-solicitation agreement or any other kind of agreement with any other employer that might restrict you from working for the Company (you will be required to furnish a copy of the agreement if you are being considered for hire)?*
- Yes
- No
If yes, explain:
PROFESSIONAL REFERENCES

(Please list three individuals unrelated to you with whom you have worked who know your qualifications for this position.)
Name:
First Last
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:
Relationship:
Name:
First Last
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:
Relationship:
Name:
First Last
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:
Relationship:
APPLICANT’S ACKNOWLEDGMENT
I certify that the answers given herein and during the entire application process (including but not limited to information provided in resumes, attachments to this application, interviews or otherwise (if applicable)) are true and complete to the best of my knowledge.

I understand that any misrepresentations, omissions of facts or incomplete answers during the application process may disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts during the application process may be cause for my dismissal at any time without prior notice.

I consent to and authorize the Company and ADP TotalSource® to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment.

I further authorize the listed employers, schools and personal references to give the Company or ADP TotalSource (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have and hereby waive any actions which I may have against either party(ies) for providing a good faith reference.

I EXPRESSLY AGREE AND UNDERSTAND THAT, IF EMPLOYED, MY EMPLOYMENT IS NOT FOR A SPECIFIC TERM, IS BASED ON MUTUAL CONSENT AND MAY BE TERMINATED BY ME OR THE COMPANY OR ADP TOTALSOURCE WITH OR WITHOUT NOTICE OR CAUSE AT ANY TIME. I FURTHER UNDERSTAND THAT NO ORAL PROMISE, EMPLOYER POLICY, CUSTOM, BUSINESS PRACTICE OR OTHER PROCEDURE (INCLUDING THE BASIC EMPLOYMENT POLICIES, PERSONNEL HANDBOOK OR ANY PERSONNEL MANUALS) CONSTITUTES AN EMPLOYMENT CONTRACT OR MODIFICATION OF THE AT-WILL EMPLOYMENT RELATIONSHIP BETWEEN ME AND THE COMPANY OR ADP TOTALSOURCE.

I ALSO UNDERSTAND THAT MY AT-WILL EMPLOYMENT STATUS WITH THE COMPANY MAY ONLY BE ALTERED IN AN INDIVIDUAL CASE OR GENERALLY IN A WRITING SIGNED BY THE OWNER, PRESIDENT OR CEO OF THE COMPANY AND THAT MY AT-WILL STATUS WITH ADP TOTALSOURCE MAY ONLY BE ALTERED IN AN INDIVIDUAL CASE OR GENERALLY IN A WRITING SIGNED BY THE PRESIDENT OF ADP TOTALSOURCE.

I understand that I may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job-related tests; take a driver’s examination or take a pre-employment drug test. If I am offered employment or start work before any required test is completed, I understand that my employment is contingent on a satisfactory result on all required tests. I authorize the Company and ADP TotalSource to release the results of my pre-employment drug/alcohol test (if any), any information on this application and any relevant information about me to each other and to other ADP TotalSource clients for whom I have applied for employment, and release the Company, ADP TotalSource and its clients from any and all claims related to the lawful release of this information. I further authorize the release of any background check results and of any drug/alcohol test to any state or federal authority requesting such information and in response to a valid subpoena or other legal document.
Do you understand and accept these terms?*
- Yes
- No
Additional Comments:
Signature:*

By typing your name you agree that all of the information presented above is true and accurate to the best of your knowledge.
Today's Date:*
MM slash DD slash YYYY

PERSONAL DATA

DRIVING RECORD

EDUCATION

EMPLOYMENT HISTORY

PROFESSIONAL REFERENCES

APPLICANT’S ACKNOWLEDGMENT

Services

Other Resources

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