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Employment Application

Employee Information
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Work Phone
Email Address*
Are you 18 years or older?*
- Yes
- No
Are you 19 years or older?*
- Yes
- No
Employment Desired
Position Desired*
Date you can start*
Date Format: MM slash DD slash YYYY
Salary Desired
Are you employed now?*
- Yes
- No
May we inquire of your present employer?
- Yes
- No
Have you ever applied to this company before?*
- Yes
- No
Where & When?
Education
Name & Location of High School*
Number of years attended*
Did you graduate?*
- Yes
- No
Extracurricular activities
Name & Location of College
Number of years attended
Did you graduate?
- Yes
- No
Subjects studied
Name & Location of Trade, Business, or Correspondence School
Number of years attended
Did you graduate?
- Yes
- No
Subjects studied
Subjects of special study or research work
General
Foreign languages you speak fluently
U.S. Military/Rank
Special membership in National Guard or Reserves
How were you referred to this organization?
Have you ever been involuntarily discharged from employment?*
- Yes
- No
When and under what circumstances?*
If hired, can you provide documents to prove that you are authorized to work in the United States?*
- Yes
- No
Is there any information we would need about your name or the use of another name for us to be able to check your work record?*
- Yes
- No
Please specify*
Have you ever been convicted of any crimes, excluding minor traffic violations?*
- Yes
- No
List the nature, date and place*
Previous Employment History
Begin with present or most recent employer
Name & Address of Employer
Position
Supervisor
Phone
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Ending Salary
Brief description of your duties
Reason for leaving
Name & Address of Employer
Position
Supervisor
Phone
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Ending Salary
Brief description of your duties
Reason for leaving
Name & Address of Employer
Position
Supervisor
Phone
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Ending Salary
Brief description of your duties
Reason for leaving
References
Please give the names of two people not related to you whom you have known at least one year.
Name/Address*
Business*
Years Acquainted*
Name/Address*
Business*
Years Acquainted*
Emergency Contact
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
United States Coast Guard Regulations require that all employees in selective job functions submit to a pre-employment drug test and participate in a random drug testing program. I understand that refusal to submit to, or a positive test result, can result in termination.*
- I understand the above statement
"I certify that the facts contained in this application are true and complete to the best of my knowledge and understanding that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed herein to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice."*
- I Agree with the above statement
Applicant*
First Last
Signature*
Date*
Date Format: MM slash DD slash YYYY
This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting employment discrimination.

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218. 722. 6218

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877. 883. 4002

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