SAMPLE JOB APPLICATION

PERSONAL INFORMATION DATE

SOCIAL – -
NAME SECURITY #
Last First
Middle
PRESENT ADDRESS
Street City
State Zip
PERMANENT ADDRESS
Street City
State Zip
PHONE # ( ) - Referred By
EMPLOYMENT DESIRED
DATE YOU SALARY

POSITION CAN START DESIRED

IF SO, MAY WE INQUIRE

ARE YOU EMPLOYED NOW? OF YOUR PRESENT EMPLOYER?

EVER APPLIED TO THIS

COMPANY BEFORE? WHERE? WHEN?

EDUCATIO NAME AND LOCATION OF
* YEARS * DATE
ATTENDE GRADUAT SUBJECTS STUDIED
N SCHOOL
D ED
GRAMMAR
SCHOOL

HIGH SCHOOL

COLLEGE

TRADE/BUSINESS OR
CORRESPONDENCE
SCHOOL

* The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of
age with respect to individuals who are at least 40 but less than 65 years of age.
FORMER (LIST BELOW LAST 6 EMPLOYERS, STARTING WITH LAST ONE
FIRST)
EMPLOYERS
DATE,
NAME AND ADDRESS OF REASON FOR
MONTH, AND SALARY POSTION
EMPLOYER LEAVING
YEAR
FROM
TO
FROM
TO

FROM
TO

FROM
TO

FROM
TO

FROM
TO

[CONTINUED ON OTHER SIDE]

REFERENCES (GIVE BELOW THE NAME OF THREE PERSONS NOT RELATED TO
YOU, WHOM YOU HAVE KNOWN FOR AT LEAST ONE YEAR)
YEARS
NAME ADDRESS BUSINESS
ACQUAINTED
1
2
3
PHYSICAL RECORD
DO YOU HAVE ANY PHYSICAL DEFECTS THAT PRECLUDE YOU FROM PERFORMING ANY WORK
FOR WHICH YOU ARE BEING CONSIDERED?

WERE YOU EVER INJURED? GIVE DETAILS

HAVE YOU ANY DEFECTS IN HEARING? IN VISION? IN SPEECH?

IN CASE OF EMER-

GENCY, NOTIFY ( ) -
Name Address Relation
Phone #
I AUTHORIZE INVESTIGATIONS OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I
UNDERSTAND THAT MISREPRESENTATION OR OMMISION OF FACTS CELLED FOR IS CAUSE
FOR DISMISSAL. FURTHER, I UNDERSTAND AND AGREE THAT MY EMPLOYMENT IS FOR NO
DEFINATE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND
SALARY, BE TERMINATED AT ANY TIME WITHOUT ANY PREVIOUS NOTICE.

DATE SIGNATURE
THIS SECTION FOR EMPLOYER USE ONLY

THE FOLLOWING IS TO BE COMPLETED BY THE EMPLOYER IF THE APPLICANT IS

HIRED
COINS [C=CAUCASIAN/O=ORIENTAL/I=AMERICAN
SEX [M/F] INDIAN/N=NEGRO/S=SPANISH]
DATE OF BIRTH -
-
EFFECTIVE DATE OF EMPLOYMENT - HOME STORE NUMBER
-
PAY CODE [H=HOURLY/S=SALARIED] REGULAR PAY RATE
REQUIRED ATTACHMENTS

__________ INSURANCE

__________ FEDERAL W-4

__________ CASH HANDLING POLICY

REMARKS

EMPLOYMENT APPROVAL

REQUESTED BY DATE
Manager

APPROVED BY DATE
Supervisor/Personnel

PAYROLL KEYPUNCHED DATE