Employment Opportunities

1. PERSONAL INFORMATION






2. POSITION APPLYING FOR




3. EDUCATION

Name & Location of School Number of Years Attended Degree Achieved Subjects Studied
Grammar School
High School
College
Graduate
Trade, Business, or Correspondence School

4. GENERAL



(exclude organizations, the name of which indicates race, creed, religion, sex, age, marital status, color, sexual orientation or national origin of its members)



5. FORMER EMPLOYERS

List below last three employers, starting with last one first.

Employer 1


Employer 2


Employer 3



6. REFERENCES

Name Address Phone Number Business Years Acquainted
A.
B.
C.

A copy of the job description is available from the facility administrator. If you can perform the job functions with an accommodation, please describe how you would perform the functions and with what accommodations.

7. READ CAREFULLY AND SIGN BELOW IF YOU AGREE TO THESE TERMS OF EMPLOYMENT

I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I AM EMPLOYED, MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME. IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE COMPANY'S RULES AND REGULATIONS. I AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT EITHER MY OR THE COMPANY'S OPTION. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE AT ANY TIME BY THE COMPANY. I UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN ITS PRESIDENT, AND THEN ONLY WHEN IN WRITING AND SIGNED BY THE PRESIDENT, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FORGOING.

8. AUTHORIZATION & WAIVER

I authorize and request my former employers, references, educational institutions, and any credit agencies or reporting services which have information about me, to give this potential employer and its subsidiaries any and all information and opinions about me in their possession and which may lawfully be disclosed. I hereby waive written notice of such release of information and opinions, and I release such former employers, references, educational institutions, and credit agencies or reporting services from any liability or claim relating to such release of information and opinions. I also authorize and request federal, state and local government agencies to release to this potential employer and its subsidiaries any information requested concerning any criminal convictions on my record. A photocopy of this signed authorization and waiver shall be valid as an original.




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