Last Name *
First Name *
Present Street Address *
Zip Code *
Mailing Address *
Phone Number *
Date of Birth *
Social Security Number (Confidential) *
Are you a student, do you have a work permit? * Select OptionYesNo
Are you able to work weekends? * Select OptionYesNo
Are you able to work holidays? * Select OptionFull TimePart Time
Are you able to be "On Call"? * Select OptionYesNo
POSITION APPLYING FOR?
This job requires lifting and standing, do you have any disabilities, that might be affected? * Select OptionYesNo
If yes, explain:
**Are you a Certified Technician with any of the binding manufacturers? * Select OptionYesNo
If yes, which one?
This job requires early hours of operation, (7 a.m.) do you have reliable transportation? * Select OptionYesNo
Do you have driver license? * Select OptionYesNo
What is your means of transportation? * Select OptionParentYourselfOther
Have you ever been convicted of a crime? * Select OptionYesNo
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.
Please list three references other than relatives or previous employers:
Please list your work experience beginning with your most recent job held
Employer Information #1
Name of Employer:
Name of Last Supervisor:
Pay / Salary:
Reason for Leaving (be specific)
Employer Information #2
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.
CHECK BOX TO CONFIRM *
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.
2 + 4 = ? Please prove that you are human by solving the equation *
Home » Sample Employment Form
Phone: (760) 249-3055
7 A.M. – 10:30 P.M. (Mon – Sun) OPEN ALL WINTER HOLIDAYS!
1327 State Highway 2 Wrightwood, CA 92397
Located right next door to the Wrightwood Mini Mart. Look for our sign!