BROWN AND WHITE, INC

 

APPLICATION FOR EMPLOYMENT

This company is EEO and ADA compliant, equal access to programs, services and employment is available to all persons.  If applicant requires accommodation for the application and/or interview process, contact Human Resources.

 

 

PLEASE PRINT

 

Position(s) Applied: ________________________________________________                Date: ______________________

 

Referral source:           £Newspaper               £Online                      £Relative/Friend         £Walk-In

 

                                    £Employment Agency                                    £Other

 

Name of source, if applicable: __________________________________________________________________________

 

Applicant Name: _____________________________________________________________________________________

                                    Last                                                                                                                                        First                                                                                                               M.I.

 

Address: ___________________________________________________________________________________________

                                                Street                                                                                                                                                             City                                                                State               Zip Code

 

Home Phone: (____) __________________________                      Best time to call: _________________am/pm

 

Work Phone: (____)___________________________                      May we contact you at work? £Yes  £No

 

If yes, best time to call: ___________________am/pm                      Cell Phone: (____) _______________________

 

Date available to work: ___________________________     Type of work: £Full-time   £Part-time   £Temporary

 

If required, will you be able to relocate?         £Yes   £No                If required, can you travel? £Yes     £No

 

If required, are you able to work overtime? £Yes   £No      

 

Do you have the legal right to work in the United States?                    £Yes   £No

(Proof of citizenship or immigration status is required upon hiring)

 

Are you over 18 years old?     £Yes   £No                Can you provide proof of age?            £Yes   £No

 

Have you ever applied to this company before? £Yes           £No                If so, when: ______________________________

 

Have you ever worked for this company before? £Yes         £No                If so, when: ______________________________

 

Who was your supervisor? _____________________________________________________________________________

 

Are you employed now? £Yes           £No    If not, how long since last employment? __________________________________

 

Have you ever been bonded? £Yes    £No    If so, name of bonding company: _________________________________

 

Have you ever been convicted of a felony? £Yes      £No               

If yes, please explain on a separate sheet, or if you prefer this can be discussed during the interview.  Conviction is not an automatic disqualification for employment, all circumstances will be considered.

 

Is there any reason you might not be able to perform the functions of the job for which you are applying? £Yes            £No

 

 

 

 

If yes, please explain: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

EDUCATION

 

Circle highest grade completed: 1  2  3  4  5  6  7  8          High school: 1  2  3  4           College: 1  2  3  4  5  6  7  8

 

Last school attended: _________________________________________________________________________________

 

Diploma/Degree, if applicable: __________________________________________________________________________

 

List any language, other than English you speak and the skill level (i.e. fluent/speak some/read/write):

___________________________________________________________________________________________________

___________________________________________________________________________________________________

 

REFERENCES

 

List 3 references, not related to you, or if not available list personal references not related to you.  Please give name, address and phone number these individuals can be contacted with.

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________

 

List any special qualifications, certificates or awards(exclude information revealing gender, race, national origin, age or any other protected status): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

List any additional information for  consideration: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

EXPERIENCE

 

Please list last three (3) employers, starting with most recent and continuing back.  Explain any gaps in employment, if necessary, on a separate sheet of paper.

 

Employer Name and Address:

Job title:

Dates employed:

Pay rate:

Phone:

Name of supervisor or contact person:

Briefly describe duties:

 

Reason for leaving:

May we contact?

 

 

 

Employer Name and Address:

Job title:

Dates employed:

Pay rate:

Phone:

Name of supervisor or contact person:

Briefly describe duties:

 

Reason for leaving:

May we contact?

 

 

 

Employer Name and Address:

Job title:

Dates employed:

Pay rate:

Phone:

Name of supervisor or contact person:

Briefly describe duties:

 

Reason for leaving:

May we contact?

 

 

All information is complete and true to the best of applicant’s knowledge, furthermore, in the event of employment, it is understood that false or misleading information given on this application or during interview(s) may result in discharge from employment. It is also understood that applicant will abide by all rules and regulations of Brown and White, Inc. and that this application is not an employment offer or contract, expressed or implied.

 

 

Applicant authorizes Brown and White, Inc. to make such investigations and inquiries of personal, employment, financial and/or medical history, as necessary for the job applied. Applicant releases employers, schools, financial institutions and/or health care providers from all liability in responding to inquiries and releasing information in connection with this application.

 

Applications are kept on file for 90 days, after which, if applicant is interested in consideration for employment another application must be submitted.

 

 

 

 

 

Signature of Applicant: ____________________________________________________   Date: _________________

 

 

 

 

Text Box: ----FOR OFFICE USE ONLY---- Interviewer:________________________________________________ Date: ______________________ Hired By:____________________________________________ Start Date:__________________ Pay:$______/hr or $______/wk Negotiated benefits: _________________________________________ Notes: __________________________________________________________________________________ Signature of Interviewer: ___________________________________________________________________