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The ___________ Corporation is an Equal Opportunity Employer and does not discriminate on the
basis of race, color, creed, religion, sex, age, marital status, national origin, disability
or other classification protected by applicable law.
NAME: __________________________________________________________________________________
Last First Middle
ADDRESS: _______________________________________________________________________________
Number/Street City State Zip Code
SOCIAL SECURITY NUMBER: __________-__________-__________
TELEPHONE NUMBER WITH AREA CODE: Day (____) _____________ Evening (____)_______________
POSITION APPLIED FOR: _______________________________ Full time ____ Part time ____
Salary Expected: $__________________________ Date Available:_______________
Have you worked for The _______________ Corporation before? Yes_____ No_____
If yes, list dates, department, and titles: ______________________________________
If previously employed, why did you leave? _______________________________________
Have you applied for employment with The ___________ Corporation before?
Yes_____ (Date ________________) No_____
Are you legally eligible to work in the United States? Yes ____ No ____
EDUCATION: (Only job-related education will be considered)
Name and Circle Did Major Course
Location Last Year You Degree
of School Completed Graduate? Received
High School _________________________ 1 2 3 4
_________________________
College _________________________ 1 2 3 4
_________________________
Other _________________________ 1 2 3 4
LIST ANY SPECIAL EXPERIENCES, QUALIFICATIONS OR SKILLS YOU HAVE THAT YOU BELIEVE WOULD
HELP YOU DO THE JOB APPLIED FOR:
LIST ANY SPECIAL LICENSES OR CERTIFICATIONS YOU HAVE THAT YOU BELIEVE WOULD HELP YOU
DO THE JOB APPLIED FOR: (List Licensing Authority, License Number, and Date of License
for each)
Do you have a valid driver's license? Yes No
If yes, what state and number: State Number _____________
LIST ANY EXPERIENCE YOU HAVE IN OPERATING COMPUTERS OR OTHER BUSINESS EQUIPMENT THAT
YOU BELIEVE WOULD BE USEFUL IN THE JOB APPLIED FOR:
IF REQUIRED FOR THE JOB YOU ARE SEEKING,
DO YOU TYPE? ______ TAKE SHORTHAND? ______
Approximate speed: TYPING _____ wpm SHORTHAND _____ wpm
PRIOR EMPLOYMENT: (Give the following information for all present and previous employers,
beginning with the most recent.)
Employer Name, Were you Disciplined?
Address, and (Warning, Suspension,
Phone Number Dates of Employment Job Title Pay Rate or Discharge) Reason for Leaving
Yes No ______________________
Yes No ______________________
Yes No ______________________
Yes No ______________________
Have you had disciplinary problems with any previous employer?
Yes _____ No _____
If yes, please name the employer and describe the circumstances:
PLEASE LIST THREE INDIVIDUAL REFERENCES FROM PEOPLE WHO ARE FAMILIAR WITH YOUR WORK,
SKILLS, ABILITY AND CHARACTER:
Name Address Phone How long known? What capacity?
_______________ _______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________ _______________
HAVE YOU EVER BEEN CONVICTED OF A CRIME OR RECEIVED A VERDICT OF ANYTHING OTHER THAN
NOT GUILTY IN ANY CRIMINAL INVESTIGATION OR PROCEEDING?
Yes _____ No _____
If yes, describe when the conviction occurred, the facts and circumstances,
and any facts pertaining to rehabilitation. (Do not list any criminal charges for
which the records have been expunged. A criminal offense will not necessarily bar
employment.):
UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF
EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL
SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS
LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.
______________________ _________________________________
Date Signature of Applicant
INFORMATION FOR APPLICANT
(Please Read Carefully Before Signing)
This application is valid for only thirty (30) days. If you have not been
employed within thirty (30) days of your application, you must re-apply for a position.
By my signature below, I agree to the following:
a. I consent to take any physical examinations, including but not limited
to tests for alcohol or drugs, that may be requested by The _________
Corporation (1) following an offer of employment and prior to
commencement of work; and (2) during the course of my employment,
consistent with applicable law, including but not limited to the
Americans With Disabilities Act. I further authorize any health care
professional who performs such an examination or who has other
information concerning my physical, mental or other medical status to
release such information to The _________ Corporation.
b. I understand that any false statements or misleading omissions made by
me in connection with my application, or in responding to requests for
information, will be sufficient grounds for my rejection as a candidate
for employment or for my immediate discharge.
c. I understand that any employment I might be offered by The _________
Corporation is at- will and of indefinite duration, and that either I or
The _________ Corporation can terminate that employment at any time with
or without notice for any or no reason, and that no agreement to the
contrary will be recognized by The _________ Corporation unless made in
writing and signed by the President of The _________ Corporation. I
understand that satisfactory completion of my provisional period will not
change my status as an at-will employee.
d. I understand that none of The _________ Corporation's practices or
policies are to be construed as imposing any binding obligations on the
Company, and that they are subject to change or deletion at any time.
e. I hereby authorize The _________ Corporation to obtain from schools,
former employers, or other individuals or institutions it contacts, any
information in their possession regarding my employment history or
qualifications for the job for which I have applied.
I understand and agree that The __________ Corporation may engage an outside
investigator to conduct an investigation of my conduct if I am accused of
wrongdoing in my employment with The _________ Corporation.
I have read this Employment Application and I understand its contents.
___________________ ___________________________________
Date Signature of Applicant
REFERENCE RELEASE FORM
I authorize The _________ Corporation to seek from all my previous and present schools
and employers, and authorize all my previous and present schools and employers to release
to The _________ Corporation, any and all information pertaining to my educational and
employment history.
If I am offered employment, I also authorize the disclosure to The _________ Corporation
of any medical history that may be necessary to verify information provided as a part of
the application process.
I release, promise to hold harmless, and covenant not to sue The _________ Corporation
on the basis of its attempts to obtain information from my previous and present schools
and employers. I release, promise to hold harmless, and covenant not to sue my previous
and present schools, employers, or health care providers on the basis of the disclosure
of information to The _________ Corporation.
__________________ ________________________________
Date Name of Applicant
______________________________________
Signature of Applicant
Prepared by: