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Employment Application

Today's Date

First Name

Last Name

Middle Initial

Street Address

City

State

Zip

Cell Phone

Secondary Phone

E-mail Address

Are you a United States Citizen or legally eligible to work in the U. S.?

Yes No

Are you 18 or over?

Yes No

Have you applied here before?

Yes No

If you answered yes to the above question, when did you apply?

Which position are you applying for

Are you currently employed?

Yes No

If so, may we contact your present employer?

Yes No

Have you been previously employed by PolyJohn Enterprises?

Yes No

If Yes, list date(s) and job title(s):

Were you referred to PolyJohn by a current employee?

Yes No

If Yes, list names and relationship to you:

Date Available to start work

Will you work overtime if asked?

Yes No

Can you work 2nd shift?

Yes No

Can you work 3rd shift

Yes No

	Name and Location	# of Years Completed	Major Area of Study	Degree/Diploma
High School
College
Technical or Certificate Programs

Employment History

Yes, I Have Previous Employment History No Previous Employment History

Please provide the following information for your previous three employers, beginning with the most recent (Do not use "see attached resume"). If you do not have any previous employment please select the "No Previous Employment History" option above.

Employer #1

	From:	To:
Dates Employed:

Job Title #1

Address #1

Name of Supervisor #1

Telephone Number #1

May we contact?

Yes No

Job Duties #1

	Start:	Finish:
Weekly Pay:

Reason for Leaving #1

Employer #2

	From:	To:
Dates Employed:

Job Title #2

Address #2

Name of Supervisor #2

Telephone Number #2

May we contact?

Yes No

Job Duties #2

	Start:	Finish:
Weekly Pay:

Reason for Leaving #2

Employer #3

	From:	To:
Dates Employed:

Job Title #3

Address #3

Name of Supervisor #3

Telephone Number #3

May we contact?

Yes No

Job Duties #3

	Start:	Finish:
Weekly Pay:

Reason for Leaving #3

Describe your qualifications for the type of employment you are seeking.

(Please include skills, special training, etc.)

Please list any special awards, honors, scholarships, or offices held.

	Name	Address	Phone #	Relationship/Occupation	Years Known
Reference #1
Reference #2
Reference #3

Please list names of supervisors, managers, or others who can comment directly on your abilities.

I Agree

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer has been extended.) I hereby release employers, schools, healthcare providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

I Agree

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.

I Agree

PolyJohn Enterprises conducts pre-employment screening. All offers are contingent upon successful completion of a controlled substances test and/or physical examination.

I Agree

PolyJohn Enterprises is an Equal Opportunity Employer. It is the policy of PolyJohn Enterprises not to discriminate in employment matters on the basis of race, creed, color, age, marital status, national origin, sex, or status with regard to public assistance or disability.

I Agree

PolyJohn Enterprises will comply with its obligation to provide reasonable accommodation to qualified individuals with disabilities.

I Agree

I have read and reviewed the information provided in this application. I certify that the information contained in the application is true and complete to the best of my knowledge and understand that if employed, falsified statements may result in termination.

I Agree

I understand and agree that, if hired, my employment is at-will. This means that if I am hired, either the Company or I can end the employment relationship at any time for any or no reason.

I've read the Privacy Policy and accept the Terms and Condition

I agree to receiving a newsletter with information and offers about products and services by third parties (optional)