Forms (Application)

APPLICATION

This is a sample application form.

We're looking for enthusiastic individuals
to become members of our extended family.

Opportunities are available throughout our company.

The Company is an
equal opportunity employer.

Application for Employment

Applicant Information

First Name	Middle Name	Last Name
Address
City		State	Zip

Phone Number	Email Address
Emergency Phone Number	Emergency Name to Contact

Martial Status	Over the age of	Availability
Position applying for		Date Available
Can you provide legal work status documents? No Yes
Have you ever been employed by this employer before? No Yes, please explain reason for leaving
Have you been convicted of a felony in the last seven years? (Such conviction may be relevant if job-related, but does not necessarily bar you from employment) No Yes, please explain

Employment History

1	Company Name
	Address
	City	State	Zip
	Supervisor Name and Title	Phone Number
	Position	Date Started
	Salary	Date Ended
	Reason for leaving

2	Company Name
	Address
	City	State	Zip
	Supervisor Name and Title	Phone Number
	Position	Date Started
	Salary	Date Ended
	Reason for leaving

Education Background

Name and location	Type	Degree

References

Name and Address	Years Known	Phone Number

Resume

Certification — Please Read Carefully

I UNDERSTAND THAT COMPANY INC., d/b/a THE COMPANY HAS IN PLACE A DISPUTE RESOLUTION PROCEDURE, AND I FURTHER ACKNOWLEDGE AND AGREE THAT IF I AM OFFERED AND ACCEPT EMPLOYMENT, ANY DISPUTE BETWEEN ME AND COMPANY, INC., d/b/a THE COMPANY RELATING TO MY EMPLOYMENT AND/OR MY SEPARATION FROM EMPLOYMENT, SHALL BE SUBMITTED WITHIN ONE (1) YEAR OF THE DAY WHICH I LEARNED OF THE EVENT AND SHALL BE RESOLVED PURSUANT TO THE TERMS AND CONDITION OF THE DISPUTE RESOLUTION PROCEDURE.

NOTICE TO TIPPED EMPLOYEES: You are hereby notified that Section 3 (M) of the Fair Labor Standards Act (The Federal Minimum Wage Law) provides as follows:

"In determining the wage of a tipped employee, the amount paid such employee by his employer shall be deemed to be increased on account of tips by an amount determined by the employer, but not by an amount in excess of 50 per centum of the applicable minimum wage rate, except that the amount of the increase on account of tips determined by the employer may not exceed the value of tips actually received by the employee. The previous sentence shall not apply with respect to any tipped employee unless (1) such employee has been informed by the employer of the provisions of this subsection, and (2) all tips received by such employee have been retained by the employee, except that this subsection shall not be construed to prohibit the pooling of tips among the employees who customarily and regularly receive tips." Some states have eliminated the tip credit or require a lower percentage of tip credit than the Federal Minimum Wage Law, in which case, State Law will apply.

I AFFIRM THAT ALL INFORMATION IN THIS APPLICATION IS TRUE AND COMPLETE. ANY MISREPRESENTATION, FALSE STATEMENT, OR OMISSION OF FACTS CALLED FOR SHALL BE GROUNDS FOR REFUSAL OF EMPLOYMENT OR IF HIRED, DISMISSAL FROM EMPLOYMENT. I UNDERSTAND THAT ANY VIOLATION OF COMPANY RULES, POLICIES, STANDARDS, AND/OR PROCEDURES SHALL BE GROUNDS FOR DISMISSAL. I AGREE TO CONFORM TO THE RULES, POLICIES, STANDARDS, AND REGULATIONS OF THE COMPANY. AND d/b/a THE COMPANY. I UNDERSTAND THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME AT THE OPTION OF THE COMPANY, d/b/a THE COMPANY OR MYSELF, AND I UNDERSTAND THAT NO REPRESENTATIVE OF THE COMPANY HAS THE AUTHORITY TO MAKE ANY MODIFICATIONS, EITHER VERBALLY OR IN WRITING TO THE CONTRARY.

IT IS THE POLICY OF COMPANY INC. AND THE COMPANY TO HIRE ONLY U.S. CITIZENS AND ALIENS WHO ARE LAWFULLY AUTHORIZED TO WORK IN THE UNITED STATES. ALL EMPLOYEES WILL BE ASKED TO VERIFY EMPLOYMENT ELIGIBILITY PRIOR TO BEGINNING WORK.

I UNDERSTAND THAT MY APPLICATION WILL REMAIN ACTIVE FOR 30 DAYS FROM THE DATE RECEIVED.

We will contact intrested indiviuals for an interview.

Adobe Acrobat pdf fill-in forms

W-4, Employee’s Withholding Allowance Certificate

I-9, Employment Eligibility Verification