Application for Employment

Today's Date *

Name *

First

Middle

Last

Social Security # *

Address *

Street, City, State, ZIP

How long have you lived in the area? *

Years and months

Telephone # *

XXX-XXX-XXXX

Home Email Address *

Confirm Email

Position(s) Applied for: *

Part Time
Full Time

Who referred you to us? *

Date available for Work: *

Salary desired: *

Are you over 17 years of age? *

Are you able to work a night shift, overtime or weekends if needed? *

Are you legally eligible for employment in this country? *

Are you willing and able to meet travel requirements? *

Have you previously been employed by the Company? *

Have you previously applied for work at the Company? *

If yes, where and date:

Driver's license number if driving is an essential job function

Number and State

Have you served in the Armed Forces of the United States? *

Branch of Service

Date of entry in service

Date of Discharge

Rank at discharge

Military training/awards received

Education: Name of High School / Preparatory

Address / City / State

Major

Degree / Diploma / Certificate

Education: Name of College / Tech School

Address / City / State

Major

Degree / Diploma / Certificate

Education: Name of Advanced Degree

Address / City / State

Major

Degree / Diploma / Certificate

List scholastic honors, offices held, and activities in college:

Skills and Qualifications *

Special training skills, licenses and/or certificates that may qualify you for employment

Employment History #1: Employer / Company Name *

Provide the following information for your past and current employers, assignments or volunteer activities, starting with the most recent.

Address *

City, State, ZIP *

Phone Number *

XXX-XXX-XXXX

Supervisor's Name & Title *

Job Title & Duties *

Reason for Leaving *

Date Employed: From *

Month/Day/Year

Date Employed: To *

Month/Day/Year

Rate of Pay: Starting *

$ per ____

Rate of Pay: Ending *

$ per ____

Employment History #2: Employer / Company Name

Address

City, State, ZIP

Phone Number

XXX-XXX-XXXX

Supervisor's Name & Title

Job Title & Duties

Reason for Leaving

Date Employed: From

Month/Day/Year

Date Employed: To

Month/Day/Year

Rate of Pay: Starting

$ per ____

Rate of Pay: Ending

$ per ____

Employment History #3: Employer / Company Name

Address

City, State, ZIP

Phone Number

XXX-XXX-XXXX

Supervisor's Name & Title

Job Title & Duties

Reason for Leaving

Date Employed: From

Month/Day/Year

Date Employed: To

Month/Day/Year

Rate of Pay: Starting

$ per ____

Rate of Pay: Ending

$ per ____

Employment History #4: Employer / Company Name

Address

City, State, ZIP

Phone Number

XXX-XXX-XXXX

Supervisor's Name & Title

Job Title & Duties

Reason for Leaving

Date Employed: From

Month/Day/Year

Date Employed: To

Month/Day/Year

Rate of Pay: Starting

$ per ____

Rate of Pay: Ending

$ per ____

Unemployment Record #1

Sate what you were doing

From

Month/Year

Unemployment Record #2

Sate what you were doing

From

Month/Year

Unemployment Record #3

Sate what you were doing

From

Month/Year

References #1 *

Name

Telephone *

XXX-XXX-XXXX

Years Known *

References #2 *

Name

Telephone *

XXX-XXX-XXXX

Years Known *

References #3 *

Name

Telephone *

XXX-XXX-XXXX

Years Known *

If you have any questions regarding this statement, please ask them of the person who provided you with this application. This application will be given every consideration, but acceptance does not guarantee that the applicant will be hired. Your application will be considered active for a period of ninety days from the date received. *

I have read and agree with the above statement.

I certify that the information provided in this application and/or accompanying resume is true and complete. I acknowledge that any misrepresentation, falsification or omission may be grounds for rejection of my application; or if discovered after I am employed, such misrepresentation, falsification or omission may result in termination of my employment. *

I have read and agree with the above statement.

I also understand that the information supplied by me, including but not limited to my Employment History, Education, Credit, Criminal History, Motor Vehicle Record, Residence History, and References, will be utilized as part of the processing procedures. I understand that a background investigation may be conducted to verify the veracity of the information submitted and to develop information concerning my character, general reputation, personal characteristics and mode of living. I hereby authorize Synergy, the worksite employer and their agents to make a thorough investigation of my past employment and release the companies and corporations supplying that information. The background investigation will be conducted only if the applicant has been interviewed and is being considered as a qualified candidate for the position. (copy) (copy) *

I have read and agree with the above statement.

I understand that I may be required to undergo a physical examination and drug/alcohol screen by a medical facility selected by Synergy and the worksite employer as a condition of my employment and subsequent to a job offer. I further understand I must successfully pass the drug/alcohol screen and be judged to be physically able to perform the essential job functions, with reasonable accommodations if necessary, to be considered for employment. *

I have read and agree with the above statement.

In consideration of my employment, I agree that my employment and compensation are "at-will" and for no definite or determinable period, and can be terminated with or without cause or notice, at any time, at the option of the Company or myself. I agree that neither this application nor any other personnel form (i.e., guidebook, benefit enrollment forms, etc.) constitutes an employment contract express or implied, with the Company. No promises or representations contrary to the foregoing are binding on the Company unless made in writing and approved in writing by the Company's president. *

I have read and agree with the above statement.

Applicant's Signature *

First

Last

Typing the applicant's first and last name and current date is the electronic signature of this application.

Date *

Name

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