APPENDIX K
MODEL EMPLOYMENT APPLICATION
[Employer]
[Employer] is an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including age, sex, color, race, creed, national origin or ancestry, religion, marital status, citizenship status, sexual orientation, political belief or disability. [In New York State, add “military status,” “prior arrest or conviction record,” and “predisposing genetic characteristics.” In New York City, also add "alienage or citizenship," “partnership status” and “status as a victim of domestic violence, stalking and sex offenses.” In Westchester, also add "familial status,” “alienage or citizenship” and “status as a victim of domestic violence, sexual abuse or stalking.” In Connecticut, add “past or present history of mental disorder,” “mental retardation,” and “learning disability, or physical disability, including but not limited to blindness."]
Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity within three (3) days of being hired. Failure to submit such proof within the required time shall result in immediate employment termination.
(PLEASE PRINT)
Personal Data
First Name Middle Last
Street Address City State Zip Code________
_____________
Home Telephone Daytime Telephone Social Security Number
Is there any additional information relative to change of name, use of an assumed name or nickname necessary to check your work and education record? If yes, please explain.
________________________________________________
Are you 18 years of age or older? Yes _____ No _____
If yes, can you show proof of age if hired? Yes _____ No ______
Have you filed an employment application with us before? Yes_____ No______
If yes, give date: _________
Have you ever been convicted of a crime? Yes _____ No _____
Conviction will not necessarily disqualify an applicant from employment. Any criminal record that has been erased, expunged, or statutorily eradicated need not be reported.
If "yes", please explain:
________________________________________________________________________
How were you referred to [Employer]? Please circle the number of the most appropriate response.
1. College Recruiter
2. Employee of [Employer]
3. Advertisement
4. Walk-in
5. Referral
6. Other ____________
Position preferences: ___________________________________________________
For what position are you applying? ______________________________________
Salary desired: $ per (specify hour, week or year)
Schedule desired: Full Time Part Time # of Hours Per Week
Could you work overtime? Yes ____ No ____
What date could you start work?
Are you currently on "lay off" status and subject to recall? Yes____ No _____
Could you travel if required by this position? Yes % of Time No
Education
High School
School Name:
City and State:
Degree or # of Years Completed:
Major or Subject:
Grade Point Average:
College
School Name:
City and State:
Degree or # of Years Completed:
Major or Subject:
Grade Point Average:
College
School Name:
City and State:
Degree or # of Years Completed:
Major or Subject:
Grade Point Average:
Graduate School
School Name:
City and State:
Degree or # of Years Completed:
Major or Subject:
Grade Point Average:
List any certificates earned or in progress, and/or any additional training programs not included in your formal education.
List any Professional Affiliations to which you belong (please do not list activities which would indicate age, sex, color, race, creed, national origin, religion, marital or family status, sexual orientation, political belief, genetic information, or disability):
Previous Employment
List your current or most recent employment first. Include work related internships, military and volunteer work.
Current Employer:
City and State:
Telephone Number:
Supervisor's Name and Title:
Position Title:
Reason for Leaving:
Salary: per Hour Week Month Year (circle one)
Dates of Employment: From: To:
May we contact this employer? Yes ______ No ______
Previous Employer:
City and State:
Telephone Number:
Supervisor's Name and Title:
Position Title:
Reason for Leaving:
Salary: per Hour Week Month Year (circle one)
Dates of Employment: From: To:
Previous Employer:
City and State:
Telephone Number:
Supervisor's Name and Title:
Position Title:
Reason for Leaving:
Salary: per Hour Week Month Year (circle one)
Dates of Employment: From: To:
Home Addresses (for the last 7 years, list most current first -- use back for more space):
Street: City: State:
Zip: County:
From - To Dates: -
Street: City: State:
Zip: County:
From - To Dates: -
Street: City: State:
Zip: County:
From - To Dates: -
Street: City: State:
Zip: County:
From - To Dates: -
References
Name Title Employer Phone Professional
Relationship
______________
Other qualifications
State any additional information you feel may be helpful to us in considering your application, including any computer skills relevant for the position for which you are applying.
____________________________________________________________________________ APPLICANT: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING:
Are you capable of performing in a reasonable manner, with
or without reasonable accommodation, the activities involved
in the job for which you have applied? Yes _____ No _____
READ CAREFULLY
Releases
In connection with my application for employment and as a condition of continuing employment, I understand that investigative background inquiries may be made on me including previous employers, schools, consumer credit, criminal convictions, motor vehicle, and other reports. These reports will include information as to my character, work habits, performance, education, compensation, and experience along with reasons for termination of employment from previous employers. Additionally, I understand that the [Employer] may be requesting information from various federal, state, and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil, and other experiences as well as claims involving me in the files of insurance companies. Furthermore, I understand that connection with my application for employment with [Employer], I am required to consent, in writing, to the issuance to [Employer] of a Consumer Report and an Investigative Consumer Report about me. Certain information about these two kinds of reports and my rights under the federal Fair Credit Reporting Act, 15 U.S.C. § 1681 et seq. have been provided to me. I have read this information carefully. I understand that if I have any questions about these reports, I may contact [Employer] Human Resources Department at _______________.
Initials
[Note: Attach Appendix M.]
I authorize, without reservation, any party or employer contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for doing so. I voluntarily and knowingly waive all rights to bring an action for defamation, invasion of privacy, or similar causes of action, against anyone providing or seeking such information. This authorization and consent shall be valid in original, fax, or copy form.
All hiring and employment at [Employer] is at-will. I understand this application is not an employment contract, nor can it be used to create one. Employment by [Employer] has no specific term and may be terminated by the employee or [Employer] with or without notice. I acknowledge that [Employer] has not made any promises or representations that differ from those contained in this paragraph.
I understand I must provide satisfactory documents to establish my identity and right to work in the United States, if I am offered a position with [Employer], and that failure to provide this evidence will result in the termination of my employment.
I understand that if I am offered a position with [Employer], I may be required to have a drug test. If a drug test establishes the use of illegal substances, the offer of employment will be withdrawn.
I release and agree to hold harmless any individual, employer, business institution or government employer from all liability with regard to furnishing information to [Employer]. I agree to release and hold harmless [Employer] from all liability with respect to the receipt of such information.
I certify that I have and will provide information throughout the hiring process, including the information on this application form and in interviews that is true and complete. I further certify that I have and will answer all questions to the best of my ability and that I have and will not withhold any information that would unfavorably affect my application for employment. I understand that if any misrepresentation or omission has been made by me verbally or in writing, any offer of employment made to me may be withdrawn or my subsequent employment may be terminated.
Applicant's Signature Date