APPLICATIONFOR EMPLOYMENT

(PLEASE PRINT)Position(s) Applied For Date of Application

How Did You Learn About Us?

[1] Advertisement € Relative € Inquiry

€ Employment Agency € Friend € Other

LastName FirstNamle - MiddleName

Addi'ess Number Sti'eet City" State ZipCode

Teleplione Number(s) ' Social Security Number (lloluntaiy)

1. I

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Best time to contact you at home is:

If you are under 18 years of age, can you provide required

proof of your eligibility to work?

Have you ever filed an application with us before?

. If Yes, give date

Have you ever been employed with us before?.

If Yes, give date

Do any of your friends or relatives, other than spouse, work here?

€ Yes

€ Yes

€ Yes

€ Yes

€ No

II] No

€ No

€ No

Are you currently employed? [1] Yes € No

May we contact your present employer? € Yes

Are you prevented from lawfuny becoming employed in this

country because of Visa or Immigration Status?

Proof of citizenship or immigration status wi77 be required upon emp7oyment. .......... € Yes

Date available for work / / What is your desired salary range?

Are you available to work: € Full-Time (please indicate 1 2 3 shift)

€ Part-Time (please indicate Mornings Afternoon Evenings)

€ No

€ No

€ Temporary (please indicate dates available 7/ - l/)

Are you currently on "lay-off" status and subject to recan? € Yes € No

Can you travel if a job requires it? € Yes € No

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

EDUCATION

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EMPLOYMENT EXPERIENCE

bilities or other protected status.

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If you need additional space, please continue on a separate sheet of paper.

List professional, trade, business or civic activities and offices held.

You may exclude membership which would revea7 gender, race, re7igion, national origin, age, ancestry, disability or other

protected status:

ADDITIONAL INFORMATION

Other Qualifieations ' - ' " = "

Summarize special jobJrelated skills and qualifications 'acquired from employi-riei'it or other exper:ence'. . '

SPF,CIALIZED SKILLS (CHECK SKILLS/EQUIPMENT Opnmmn)

Terminal

PC/MAC

Spreadsheet

Word Processir4g

Shorthand

Produ6tion/Mobile

Machineiy(list) Other (list) '

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Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN

INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Can you perform the essential functions of the job, for which you are applying, either with or without a

reasonableaccommodation? YES NO

REFERENCES

(NameC

(Address)

(Name)

(Address)

(Nan"ie)

Phone #

Pl"ione #

Plione #

(Adch'ess)

APPLICANT'S STATEMENT

I certity that given true and complete.

I authojize investigation of-all stateinents contained in this application for employment as may benecessary in amving at an employinent decision.

This applicatipn for employment shall be considered act.ive for a period of'time not to exceed 45

days. Any applicant wishing to be considered for'employment beyond this time period shouldinquire as to whether or not applications are being accepted at that time.

I hereby rinderstand and acknowledge that, unless otherwise defined by applicable law, any

employment relationship with this organization is of an "at wilr' nature, which means that the

Employee may resign at,any time and the Employer may discliarge Employee at any time with or

witliout cause.

In the event of employrnent, I undeystand that false or misleading information given in rny

application or interview(s) may result in discharge. I rinderstand, also, that I am required to abideby all.rules and regulations of the employer.

Signature of Applicant Date

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An-ange Intei'view € Yes € No

' Remarks '

INTERV[EWER DATE

. Employed - € Yes € No' Date of Employrnent

.Job Title " HOuSralAryRaIe' Department

B37NAMEA_%"DTffLE . ' DATE

This Application For Employment is sold for general use throughout the United States. Arnsterdam Printing assumes no responsibility for the use of

said form or any questions wich, when asked by the employer of the 3ob applicant, may violate State and/or Federal Law.

Rev 11/13 Re-order Form #23960 (23962 imprinted) (Ccopyright 2013 Arnsterdam Printing, Amsterdam, N.Y. 12010Tou Free 1-866-466-1438 or onJine wiavw.amsterdamforms.com tlihybieidam