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Application for Part Time Employment

  1. We are an equal opportunity employer. We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical or disability, or any other legally-protected status.
  2. How did you learn about us?
  3. Have you ever filed an application with us before?*
  4. Have you ever been employed with us before?*
  5. Are you currently employed?
  6. May we contact your present employer?
  7. Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? (Proof of citizenship or immigration status will be required upon employment)*
  8. Are you available to work:
  9. Are you currently on "lay-off" status and subject to recall?*
  10. Have you been convicted of a felony within the last 7 years? (Conviction will not necessarily disqualify an applicant from employment.)*
  11. Education
  12. Elementary School grades / years completed:
  13. Middle school grade / years completed:
  14. High school grades / years completed:
  15. Years of college completed:
  16. Years of graduate / professional school completed:
  17. References
  18. Give names, addresses and phone numbers of three references who are not related to you and are not previous employers.
  19. Reference 1:
  20. Reference 2:
  21. Reference 3:
  22. Former Employers
  23. List your last four employers, starting with the most recent one first:
  24. Physical Record
  25. Do you have any physical limitations that preclude you from performing any work for which you are being considered?
  26. Emergency Notification
  27. In case of emergency, notify:
  28. Notice
  29. 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 the references 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 all parties from all liability for any damage that may result from furnishing same to you. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice.
  30. Name of person submitting electronic employment application:
  31. The undersigned, referred to as “Applicant”, hereby authorizes the organization either directly or through its agent to investigate Applicant’s background. This may include information as to character, financial responsibility, criminal and/or civil records. Records from public and private sources may be reviewed concerning criminal history, civil court cases, credit history and references. Applicant acknowledges that a fax or photographic copy shall be as valid as the original. Applicant further understands that a complete disclosure of the nature and scope of this investigation may be obtained by a written request received within ninety days. The information below is required to obtain requested records and must be completed by all Applicants. The organization requests this information for the sole purpose of facilitating the investigation of Applicant. Certain information provided herein by Applicant will not be considered or used by the organization in determining whether Applicant will be accepted as an employee. This information is denoted below by an asterisk (*).
  32. Current Address Information:
  33. I hereby authorize, without reservation, any law enforcement agency, company, institution, credit bureau, or references contacted by the organization or its agent, to furnish the information described above.
  34. Leave This Blank:

  35. This field is not part of the form submission.