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Employment Application

Employment Application

Prospective employees will receive consideration without discrimination based on race, color, gender, age, sexual orientation, national origin, disability or military status. 

Personal Information

Full Name:
First Name *
Middle *
Last Name *
Have you worked under any other names? Please indicate names & years. If no, indicate with NA.
Full Address:
Country
Address Line 1 *
City *
State/Province *
Postal Code *
Primary Telephone:
Position Applying for:
Expected Pay:
What type of employment are you seeking?
What type of employment are you seeking?
Are you 18 years old or older?
Are you 18 years old or older?
Are you legally eligible to work in the United States?
Are you legally eligible to work in the United States?
When will you be available to begin work?
Have you been convicted of any crimes in the past 10 years?
Have you been convicted of any crimes in the past 10 years, excluding misdemeanors and summary offenses which have not been annulled, expunged or sealed by a court?
If yes, please describe in full. If no criminal history please indicate NOT APPLICABLE (NA). (A criminal record or a conviction will not automatically bar employment bull will be considered only as it reasonably relates to your fitness to perform the position for which you are applying.)
Are you a licensed provider in the State of Georgia?

Education

Graduate School:
Name of Graduate School
Location (City, State):
Course of Study:
Number of years completed?
Did you graduate?
Did you graduate?
Degree or Diploma description:
College or University:
College Name:
Location (City, State):
Course of Study:
Number of years completed?
Did you graduate?
Did you graduate?
Degree or Diploma description:
Business/Trade/Technical School:
School Name:
Location (City, State):
Course of Study:
Number of years completed?
Did you graduate?
Did you graduate?
Degree or Diploma description:
High School:
School Name:
Location (City, State):
Did you graduate?
Did you graduate?
Degree or Diploma description:

Employment History

Please give accurate, complete full-time and part-time employment record for at least the past 10 years, if applicable.  If current employment has lasted 10 or more years, please list two previous employers.  Start with present or most recent employer.  Please complete ALL SECTIONS even if you submit a resume.  

Employer #1
Company Name:
Address:
City, State Zip:
Telephone:
Name of Supervisor:
Employment Dates: (From & To)
(State Months & Years)
Job Title and Describe Your Work:
Rate of Pay: (Start and Last)
Reason for Leaving:
May we contact this employer?
May we contact this employer?
Are you eligible for rehire?
Are you eligible for rehire?
If not, why?
Employer #2
Company Name:
Address:
City, State Zip:
Telephone
Name of Supervisor:
Employment Dates: (From & To)
(State Months & Years)
Job Title and Describe Your Work:
Rate of Pay: (Start and Last)
Reason for Leaving
May we contact this employer?
May we contact this employer?
Are you eligible for rehire?
Are you eligible for rehire?
If not, why?
Employer #3
Company Name:
Address:
City, State Zip:
Telephone:
Name of Supervisor:
Employment Dates: (From & To)
(State Months & Years)
Job Title and Describe Your Work:
Rate of Pay: (Start and Last)
Reason for Leaving:
May we contact this employer?
May we contact this employer?
Are you eligible for rehire?
Are you eligible for rehire?
If not, why?
Employer #4
Company Name:
Address:
City, State Zip:
Telephone:
Name of Supervisor:
Employment Dates: (From & To)
(State Months & Years)
Job Title and Describe Your Work:
Rate of Pay: (Start and Last)
Reason for Leaving:
May we contact this employer?
May we contact this employer?
Are you eligible for rehire?
Are you eligible for rehire?
If not, why?
Employer #5
Company Name:
Address:
City, State Zip:
Telephone:
Name of Supervisor:
Employment Dates: (From & To)
(State Months & Years)
Job Title and Describe Your Work:
Rate of Pay: (Start and Last)
Reason for Leaving:
May we contact this employer?
May we contact this employer?
Are you eligible for rehire?
Are you eligible for rehire?
If not, why?
Do you belong to any professional, trade, business, or civic organizations that relate to the position for which you are applying? If yes, please explain and list the offices held. (Omit any organizations which reflect your race, color, religion, age, gender, sexual orientation, marital status, or disabilities.)

References

Please give three references, not relatives or current employers, who would be willing to discuss your character and work habits.  

1. Reference Name:
First Name *
Last Name *
Company or Affiliation:
Telephone:
2. Reference Name:
First Name *
Last Name *
Company or Affiliation:
Telephone:
3. Reference Name:
First Name *
Last Name *
Company or Affiliation:
Telephone:
Can you perform the essential functions of the position for which you are applying, with or without reasonable accommodation?
Can you perform the essential functions of the position for which you are applying, with or without reasonable accommodation?
If answer NO above, please explain. If you need no accommodations at the time of application, please indicate with NOT APPLICABLE (NA). (If you have any questions as to what functions are applicable to the positions for which you are applying, please ask the interviewer before you answer this question.)
Please add a link if you have a personal website you'd like to share.
How did you hear about this position?

Applicant's Signature

Please read and understand this statement before signing your application: 

The information I have provided in this application for employment is true, correct and complete.  False, incomplete or misrepresented information of any kind will be sufficient cause for my application to be rejected, or if discovered after I am employed, cause for immediate termination of employment.  

I authorize the employer to contact and obtain information about me from previous employers, educational institutions and references I provided, and any other party necessary to verify the accuracy of the information I disclosed in the application, a related employment resume or a personal interview.  To assist in the processing of my application, I waive all rights and claims I may otherwise have against the employer or the representatives, for seeking, and using the information to evaluate my employment request, and all other persons, corporations or organizations who provide information for this purpose.  

I understand I will be required to submit to a criminal background check and a drug screening examination.  I hereby consent to these tests as a condition of employment.  

This application will expire in 60 days.  After that date, unless otherwise notified, I understand that my status as an applicant will end.  I may re-apply for employment in the future by completing a new application.  

This application is not an employment agreement.  If I accept an offer of employment I understand I may resign at any time, and the employer may terminate my employment at any time, with or without cause and without prior notice, unless required by law.  I understand that no one, other than an executive officer of the employer, has the authority to enter into any employment agreement with terms contrary to the foregoing and then only in writing signed by each officer.  

I fully understand and accept all terms and conditions in the above statement.  

I have read the above and understand.
I have read the above and understand.
By Typing Full Name I Submit As A Digital Signature
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