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Employment Information

Please provide all employment information for your past four employers, starting with the most recent.

Employer 2

Employer

Address

City

State

Zip

Immediate supervisor and title

Phone

Position held

Salary

Job summary

Dates Employed

Reason for leaving

Employer 3

Employer

Address

City

State

Zip

Immediate supervisor and title

Phone

Position held

Salary

Job summary

Dates Employed

Reason for leaving

Employer 4

Employer

Address

City

State

Zip

Immediate supervisor and title

Phone

Position held

Salary

Job summary

Dates Employed

Reason for leaving

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.

I also understand that if I am employed, I will be required to provide satisfactory proof of legal identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

Background Information

Position Information

Employment Information

Employer 1

Employer 2

Employer 3

Employer 4

Other Skills and Qualifications

Educational History

References

Reference 1

Reference 2

Reference 3

Acknowledgements*

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