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APPLICATION FOR EMPLOYMENT

All applicants are considered for all positions without regard to race, religion, color, sex, gender, sexual orientation, pregnancy, age, national origin, ancestry, physical/mental disability, medical condition, military/veteran status, genetic information, marital status, ethnicity, citizenship or immigration status, or any other protected classification, in accordance with applicable federal, state, and local laws. By completing this application, you ar e seeking to join a team of hardworking professionals dedicated to consistently delivering outstanding service to our customers and contributing to the financial succes s of the organization, its clients, and its employees. Equal access to programs, services, and employment is available to all qualified persons. Those applicants requiring an accommodation to complete the application and/or inter view process should contact a management representative.

Position(s) applied for

Date of application

Print full name

Street address

City

State

ZIP

Main phone number

Alternate phone number

Email

EMPLOYMENT EXPERIENCE

Please list the names of your present or previous employers in chronological order with present or most recent employer listed first. Be sure to account for all periods of time. If self-employed, give firm name and supply business references. Add an additional page if necessary.

Previous/Current Position: 1

Name of employer

Supervisor

May we contact?

Yes No

Street address

Phone Number

Dates employed (month/year): FROM

Dates employed (month/year): TO

Job title and duties

Reason for leaving

Previous/Current Position: 2

Name of employer

Supervisor

May we contact?

Yes No

Street address

Phone Number

Dates employed (month/year): FROM

Dates employed (month/year): TO

Job title and duties

Reason for leaving

Previous/Current Position: 3

Name of employer

Supervisor

May we contact?

Yes No

Street address

Phone Number

Dates employed (month/year): FROM

Dates employed (month/year): TO

Job title and duties

Reason for leaving

Have you ever been involuntarily terminated or asked to resign from any job?

Yes No

If yes, please explain.

Please explain any gaps in your employment history.

Please list any other experience, job-related skills, additional languages, or other qualifications that you believe should be considered in evaluating your qualifications for employment.

EDUCATION

Please describe your education below.

High school

School name

Diploma/ degree

Yes No

Area of study/major

Specialized training, skills, or extracurricular activities

College/ University

School name

Diploma/ degree

Yes No

Area of study/major

Specialized training, skills, or extracurricular activities

Graduate/ Professional School

School name

Diploma/ degree

Yes No

Area of study/major

Specialized training, skills, or extracurricular activities

Trade School

School name

Diploma/ degree

Yes No

Area of study/major

Specialized training, skills, or extracurricular activities

Other

School name

Diploma/ degree

Yes No

Area of study/major

Specialized training, skills, or extracurricular activities

BUSINESS AND PROFESSIONAL REFERENCES

Please list three professional references of individuals who are not related to you.

Name and title

Relationship

Phone number or email

Name and title

Relationship

Phone number or email

Name and title

Relationship

Phone number or email

PERSONAL REFERENCES

Please list three people who know you well.

Name and title

Relationship

Phone number or email

Name and title

Relationship

Phone number or email

Name and title

Relationship

Phone number or email

GENERAL INFORMATION

1. Have you ever used another name?

Yes No

2. Is any additional information relative to name changes, use of an as sumed name, or nickname necessary to enable a check on your work and educational record?

Yes No

If yes to either of the above, please explain:

3. Have you ever worked for this company before?

Yes No

If yes, please provide dates and position:

4. Do you have friends and/or relatives working for this company?

Yes No

If yes, name(s) and relationship(s):

5. On what date are you available to begin work?

6. Days/hours available to work:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

7. Are you available to work?

Full-time Part-time Shift Work Temporary

8. If hired, would you have a reliable means of transpor tation to and from work?

Yes No

9. Can you travel if the position requires it?

Yes No

10. Can you relocate if the position requires it?

Yes No

11. Are you at least 18 years old? Note: If under 18, hire is subject to verification that you are of minimum legal age.

Yes No

12. If hired, can you present evidence of your identity and legal right to work in this country?

Yes No

13. Are you able to perform the essential job functions of the job for which you are applying with or without reasonable accommodation? Note: We comply with the Americans with Disabilities Act and consider reasonable accommodation measures that may be necessary for qualified applicants/employees to perform essential job functions.

Yes No

APPLICANT STATEMENT AND AGREEMENT

Please read and initial each paragraph below. If there is anything that you do not understand, please ask.

I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the prior employers and references I have listed to disclose to the company any and all letters, repor ts, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers, and all other persons, corporations, partnerships, and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure.

In the event of my employment with the company, I understand that I am required to comply with all rules and regulations of the company.

If hired, I understand and agree that my employment with the company is at will and that neither I nor the company is required to continue the employment relationship for any specific term. I fur ther understand that the company or I may terminate the employment relationship at any time, with or without cause, and with or without notice. I underst and that the at-will status of my employment cannot be amended, modified, or altered in any way by any oral modifications.

I understand that the safety of employees is extremely important to the company and that the company is committed to ensuring a safe working environment. I understand that I, and every employee, have a responsibility to prevent accidents and injuries by observing all safety procedures and guidelines and following the directions of my site super visor. I understand and agree to comply with federal, state, and local regulations related to on-the-job safety and health.

I hereby certify that the answers given by me are true and correct to the best of my knowledge. I fur ther certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I understand that if I am selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration law requires me to complete an I-9 Form in this regard.

I understand that if any term, provision, or por tion of this Agreement is declared void or unenforceable, it shall be severed and the remainder of this Agreement shall be enforceable.

My signature attests to the fact that I have read, understand, and agree to all of the above terms.

E-Signature: Full Name

Date

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Located in Pittsburgh, PA 15209

Call us at (412) 390-4106
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