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Personal Information
Last Name
First Name
Middle Name
Present Address: (Street, City, State, Zip)
Permanent Address: (Street, City, State, Zip) *
Phone Number:
Referred By: (First, Last)
Are you 18 years of age or older?
yes
no
Have you ever applied to this company before?
yes
no
What Location Are You Applying For ?
When?
Position Desired
Date you can start
Salary Desired
Are you employed now?
yes
no
If so, may we inquire of your present employer?
yes
no
Education
Grammar School
Did you graduate?
yes
no
Subjects Studied
High School
Last year completed
1
2
3
4
Did you graduate?
yes
no
Subjects Studied
College
Last year completed
1
2
3
4
Did you graduate?
yes
no
Subjects Studied and Degree(s) Received
Trade, Business or Correspondence School
Last year completed
1
2
3
4
Did you graduate?
yes
no
Subjects Studied and Degree(s) Received
General Questions
Subjects of Special Study or Research Work
Job Related Skills (typing, driver's license, etc.)
Activities Other Than Religious (Civic, Athletic, etc.) Exclude organizations the name or character of which indicates the race, sex or national origin of it's members.
Former Employers & References
FORMER EMPLOYER #1 - (Include dates (from and to) Name and address of employer, salary upon leaving, position and reason for leaving.)
FORMER EMPLOYER #2 - (Include dates (from and to) Name and address of employer, salary upon leaving, position and reason for leaving.)
FORMER EMPLOYER #3 - (Include dates (from and to) Name and address of employer, salary upon leaving, position and reason for leaving.)
FORMER EMPLOYER #4 - (Include dates (from and to) Name and address of employer, salary upon leaving, position and reason for leaving.)
REFERENCES: List 3 persons NOT related to you, whom you have known for at least one year. (Include: Full Name, Address, Position and Years Acquainted)
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UNDER MARYLAND LAW AN EMPLOYER MAY NOT REQUIRE OR DEMAND ANY APPLICANT FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT OR ANY EMPLOYEE TO SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT, ANY EMPLOYER WHO VIOLATES THIS PROVISION IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT TO EXCEED $100." "It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. If you are hired by the company, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements. AUTHORIZATION I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by the Company. I understand that any employment is conditioned on a background check. I authorize the Company to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, character and general reputation to the Company, without giving me prior notice of such disclosure. In addition, I release the Company, any former employers and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure. I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be "at will" and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the Company. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Company unless made in writing. If I am offered employment I agree to submit to a medical examination and drug test before starting work. If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by the Company and as permitted by law. I consent to such examinations and tests, and I request that the examining doctor disclose to the Company the results of the examination, which results shall remain confidential and segregated from my personal file. I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drug test, and if I am hired a condition of my employment will be that I abide by the Company's Drug and Alcohol Policy. I understand that filling out this form does not indicate there is a position open and does not obligate the Company to hire. If hired, I agree to abide by all Company work rules, policies and procedures. The Company retains the right to revise its policies or procedures, in whole or in part, at any time. By choosing YES I agree to the statements above: *
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