Job Application: Stroud’s Independence

Title: Stroud’s Independence

Fields marked with an asterisk (*) must be filled out before submitting.

Employment Application

Applicant Name *
Date *
Position(s) applied for or type of work desired *

Contact Details

Address *
City *
State *
Zip Code *
Telephone # *
Cell Phone # *
Type of employment desired * Full Time
Part Time
Temporary
Date you will be available to start work *
Days available to work * Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Are you able to meet the attendance requirements? * Yes
No
Do you have any objection to working overtime if necessary? * Yes
No
Can you travel if required by this position? * Yes
No
Have you ever been previously employed by our organization? * Yes
No
Can you submit proof of legal employment authorization and identity? Yes
No
If you are under 18, can you furnish a work permit if it is required? Yes
No
Have you ever been convicted of a crime in the last 7 years? Yes
No
If yes, please explain (a conviction will not automatically bar employment)
Drivers license number (if driving is an essential job duty)
How were you referred to us?

Employment History

May we contact your current employer? Yes
No
Most Recent Employer
Position held
Address
Telephone #
Immediate supervisor and title
Dates employed
Salary
Job summary
Reason for leaving
Previous Employer
Position held
Address
Telephone #
Immediate supervisor and title
Dates employed
Salary
Job Summary
Reason for Leaving
Previous Employer
Position Held
Immediate supervisor and title
Address
Telephone #
Dates Employed
Salary
Job Summary
Reason for Leaving

Other Skills and Qualifications

Summarize any job­ related training, skills, licenses, certificates, and/or other qualifications

Educational History

High School
College
Technical Training
Other

References

Reference #1 Name
Years Known
Telephone Number
Reference #2 Name
Years Known
Telephone Number
Reference #3 Name
Years Known
Telephone Number
 

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 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.

 

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Please select Yes
No