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Employment Application

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Position Appying for:  
 
Contact Data
First Name:  
Last Name:  
Telephone:  
Alternate Telephone:  
Email:  
Street Address:  
City, State, Zip Code:  
 
Personal Data
I am seeking a permanent position:  
Are you legally eligible for employment in the United States?  
Do you have a valid Illinois Driver's License?  
Are you able to perform the essential functions of the position with or without accommodations?  
I can work the following shifts:  
Can you work overtime:  
If necessary for the job are you older than:  
If accepted fpr employment, when can you start:  
 
Employment History
List most recent employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here, in the summary following this section or on an extra sheet of paper if necessary. No more than 10 years history recommended.
Most Recent or Current Employer:  
Address:  
City, State, Zip Code:  
Supervisor Name:  
Phone:  
Email:  
Position:  
Start Date/End Date:  
Final Salary:  
Reason for Leaving:  
 
Next Employer:  
Address:  
City, State, Zip Code:  
Supervisor Name:  
Phone:  
Email:  
Position:  
Start Date/End Date:  
Final Salary:  
Reason for Leaving:  
 
Next Employer:  
Address:  
City, State, Zip Code:  
Supervisor Name:  
Phone:  
Email:  
Position:  
Start Date/End Date:  
Final Salary:  
Reason for Leaving:  
 
Education/Skills/Qualifications
Highest Education Achieved:  
Are you a veteran?  
List all skills and qualifications:  
 
References
List two personal references who are not relatives or former supervisors.
Reference No. 1 Name:  
Address, City, State, Zip Code:  
Daytime Phone:  
Relationship:  
 
Reference No. 2 Name:  
Address, City, State, Zip Code:  
Daytime Phone:  
Relationship:  
 
Information to the Applicant
As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references. If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms. I understand and agree to the information shown above.
I agree the information provided above is true:  
 
Equal Employment Opportunity:
While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment.