Application for Employment

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodations to the application and/or interview process should notify a representative of the Human Resources Department.

Applicant Information
* Position(s) applied for
Rerral Source






If other, please list
Name of source (if applicable)
* First Name
Middle Name
* Last Name
* Street Address
Apartment/Unit #
* City
* State (SD)
* Zip Code (55555)
* Phone Number (555-555-5555)
Cell Number (555-555-5555)
If necessary, the best time to contact you at home is

May we contact you at work?

If yes, phone number (555-555-5555)
Best time to call

Certain positions require applicants to be 18 years or older. Do you meet this requirement?

If no, please explain
Have you submitted an application here before?

If yes, list date(s) and position(s) (01/01/19)
Have you ever been employed here before?

If yes, give dates (01/01/19)
* Are you legally eligible for employment in this country?

Date you will be available for work (01/01/19)
What is your desired hourly rate/salary range?
Type of employment desired



Will you travel if the job requires it?

Are you able to meet attendance requirements of the job?

Will you work overtime if required?

Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?

If yes, provide date(s) and details
Answering "Yes" to these questions does not constitute an automatic ban to employment. Factors such as date of the offense, seriousness of the violation, rehabilitation and position applied for will all be taken into account.
Driver's license number if driving is an essential job function
DL State
CDL license number (if applicable)
CDL State
Educational Background

A. List last three (3) schools attended, starting with the most recent. B. Number of years completed. C. Degree or diploma earned, if any. D. Grade point average or class rank. E. Major field of study. F. Minor field of study (if applicable).

School
Years Completed
Degree/Diploma
Major
Minor

School
Years Completed
Degree/Diploma
Major
Minor

School
Years Completed
Degree/Diploma
Major
Minor
References

List name and telephone number of three (3) business/work references who are NOT related to you and are NOT previous supervisors. If not applicable, list three (3) school or personal references who are NOT related to you.

Full Name
Phone Number (555-555-5555)
Years Known

Full Name
Phone Number (555-555-5555)
Years Known

Full Name
Phone Number (555-555-5555)
Years Known
Additional Information
List professional, trade, business or civic associations and any offices held
Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, Veteran/Reserve National Guard or any other similarly protected status.
List special accomplishments, publications, awards, etc.
Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, Veteran/Reserve National Guard or any other similarly protected status.
List any additional information you would like us to consider
Employment History

Provide the following information about your past and current employers, assignments or volunteer activities, starting with the most recent. Explain any gaps in employment in comments section below.

Employer
Address
City
State
Zip Code
Phone Number (555-555-5555)
May we contact for reference?


Starting / Final Job Title
Immediate Supervisor / Title
Start Date (01/01/19)
End Date (01/01/19)
Starting Hourly Rate / Salary
Final Hourly Rate / Salary
Reason for leaving
Summarize the type of work performed / job responsibilities

Employer
Address
City
State
Zip Code
Phone Number (555-555-5555)
May we contact for reference?


Starting / Final Job Title
Immediate Supervisor / Title
Start Date (01/01/19)
End Date (01/01/19)
Starting Hourly Rate / Salary
Final Hourly Rate / Salary
Reason for leaving
Summarize the type of work performed / job responsibilities

Employer
Address
City
State
Zip Code
Phone Number (555-555-5555)
May we contact for reference?


Starting / Final Job Title
Immediate Supervisor / Title
Start Date (01/01/19)
End Date (01/01/19)
Starting Hourly Rate / Salary
Final Hourly Rate / Salary
Reason for leaving
Summarize the type of work performed / job responsibilities

Employer
Address
City
State
Zip Code
Phone Number (555-555-5555)
May we contact for reference?


Starting / Final Job Title
Immediate Supervisor / Title
Start Date (01/01/19)
End Date (01/01/19)
Starting Hourly Rate / Salary
Final Hourly Rate / Salary
Reason for leaving
Summarize the type of work performed / job responsibilities

Comments (include explanation of any gaps in employment)
Skills & Qualifications
Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.
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 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.

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, resume 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 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 this application remains current for 60 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 understand 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 also understand that all new hires must satisfactorily pass required post offer/pre-employment drug screening tests as a condition of employment at Rush-Co and, if hired, will submit to random drug testing.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

* Signature of Applicant
* Signature Date

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