EMPLOYMENT APPLICATION

CONTACT INFORMATION

First Name			Last Name
Address			City
State			Zip Code
Township			Social Security Number
Phone Number			Alternate Phone
Emergency Contact Name			Emergency Contact Number
PA Drivers License Number			Date of Birth (optional)
18 or Older	Yes	No

PRIOR WORK EXPERIENCE
(begin with previous or current)
*note: if not applicable list military or volunteer service

Company		Position Held
Location		Phone
Supervisor		Rate/Salary
Dates Worked	From To
Reason for Leaving

Company		Position Held
Location		Phone
Supervisor		Rate/Salary
Dates Worked	From To
Reason for Leaving

Company		Position Held
Location		Phone
Supervisor		Rate/Salary
Dates Worked	From To
Reason for Leaving

AVAILABILITY

Date You Can Start
Position Applying For	Regular Full Time Seasonal Full Time

EDUCATION
(begin with most recently attended or currently attended)

Name		Field of Study
Location		Phone
Counselor		Did You Graduate Yes No
Last Year Completed		Currently Enrolled Yes No
Extracurricular Activities

ADDITIONAL INFORMATION

Please detail any additional skills you have that may aid you in this line of work.

LIMITATIONS

Are there any reasons why you may have difficulty performing any of the essential tasks of the job for which you have applied?

Yes No If “Yes”, describe in full

CRIMINAL RECORD

Have you been convicted of a crime in the past five years?

Yes No If “Yes”, describe in full

AUTHORIZATION

By checking this box I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.