Application for Employment

Application for Employment
  Position:      Date of Application:  

/ /

 
Position applying for.
    
MM           DD            YYYY
  Name:      
 
Last
               First
                                       Middle
  
  Address:      
 
Street
               City
                                     State
                                 Zip
  Telephone: 
Email Address:    
  (Area Code) 555-5555
          Example: somename@hotmail.com, somename@yahoo.com
 
  Are you able to provide documentation showing that you are legally eligible for employment in this country?          
 
  Have you ever been employed by Penn Warranty before? If yes, give dates and positions.    
       
  Start Date:    / / Desired Salary?          $
    MM           DD            YYYY    
  Employment Type:                                  
       
  Are you capable of meeting the attendance requirements of the position?
       
  Have you ever pled "Guilty" or "no contest", or have been convicted of, a crime?
  Answering "yes" to this question does not constitute an automatic denial of employment. Factors such as date of the offense, seriousness, and nature of the   violation, rehabilitation, and position applied for will be taken into account.
  If yes, please provide date(s) and details:          
       
  Driver's License number if driving is an essential job function:   State:   Expiry Date:  / /
     
                                                   MM           DD           YYYY
 
  Employment History
    Starting with your most recent employer, assignments or volunteer activities, provide the following information.
       
From ( Month / Year )
/ 		To ( Month / Year )
/ 		Employer
 Telephone #
Starting job title/final job title
 Street Address                                       City                                     State                         Zip
     
Immediate supervisor and title
 Summarize the nature of work performed and job responsibilities
May we contact for reference?
Yes      No      Later		 Compensation   Hourly   Salary
                                                         Start $  Per   Final $  Per 
Reason for Leaving
  
From ( Month / Year )
/ 		To ( Month / Year )
/ 		Employer
 Telephone #
Starting job title/final job title
 Street Address                                       City                                     State                         Zip
     
Immediate supervisor and title
 Summarize the nature of work performed and job responsibilities
May we contact for reference?
Yes       No       Later		 Compensation    Hourly    Salary
                                                         Start $   Per    Final $   Per 
Reason for Leaving
  
From ( Month / Year )
/ 		To ( Month / Year )
/ 		Employer
 Telephone #
Starting job title/final job title
 Street Address                                       City                                     State                         Zip
     
Immediate supervisor and title
 Summarize the nature of work performed and job responsibilities
May we contact for reference?
Yes       No       Later		 Compensation    Hourly    Salary
                                                         Start $   Per    Final $   Per 
Reason for Leaving
  
 
Skills and Qualifications
Word
MS Works
MS Office
Power Point
Internet
Summarize any training, skills, licenses and/or certifications that may quality you as being able to perform job-related functions in the position for which you are applying.
 
Educational Background (If job related)
School ( Include City and State )
Number of Years Completed
Level of Completion
Course of Study
GED Diploma Degree
GED Diploma Degree
GED Diploma Degree
GED Diploma Degree
 
References
Name
Title
Relationship to Candidate
Telephone
Years Known
 
Applicant Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resumé or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be
considered for employment, it will be necessary to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws
require me to complete an I-9 Form in this regard.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered.
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