Employment Application Name * Name First First Last Last Address * City * State * Zip Code * Personal Phone ###-###-#### * Business Phone # Email Age * Yes No Are you 18 years old? Position Applying For Date you are available? Salary Desired Are you currently employed? * Yes No IF SO, may we contact your current employer? * Yes No What type of work are you looking for? * Regular Full-time work Regular Part-time work Temporary work Are you Legally allowed to work in the US? * Yes No Do you have reliable transportation? * Yes No Who referred you to this company? * Ad for job opening Employment Agency Walk in Unemployment Office Friend / Family Employee Name of who referred you * Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation? * Yes No If no, describe the functions that cannot be performed / accommodations needed. School Level High School College / University Vocational / Business Other Did you graduate? Yes No Name & Location of School # of years completed Degree / Diploma NAME OF PRESENT OR LAST EMPLOYER * Address City State Zip Code Job Title Start Date Leave Date May we contact your supervisor? Yes No Starting Wage Final Wage Supervisor (Name & Title) Phone # Description of Job Duties Reason for Leaving NAME OF PREVIOUS EMPLOYER Address City State Zip Code Job Title Start Date Leave Date May we contact your supervisor? Yes No Starting Wage Final Wage Supervisor (Name & Title) Phone # Description of Job Duties Reason for Leaving NAME OF PREVIOUS EMPLOYER Address City State Zip Code Job Title Start Date Leave Date May we contact your supervisor? Yes No Starting Wage Final Wage Supervisor (Name & Title) Phone # Description of Job Duties Reason for Leaving MILITARY EXPERIENCE: Please list special skills or abilities acquired in the service. CONVICTIONS: Have you ever been convicted of a criminal offense (Felony or Serious Misdemeanor)? Yes No If YES, state the nature of the crime(s), when and where convicted, and disposition of the case(s). Convictions will not necessarily disqualify an applicant for employment. Special Licenses or Certifications Other Experience, Training, Qualifications, or Skills that you feel are relevant to employment with this company. PROFESSIONAL REFERENCES Name Title Company Phone # Years Associated Name Title Company Phone # Years Associated Name Title Company Phone # Years Associated AUTHORIZATIONS Truthfulness of Application: * I certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that the misrepresentation or omission of material facts may result in termination of my employment. Authorization to Investigate: * I authorize any of the persons or organizations referenced in this application to give Gilliam Electric, Inc. any and all information concerning my previous employment, education, or other information they might have, with regard to any of the subjects covered by this application, and release all such parties from the liability for any damage that may result from furnishing such information. I authorize Gilliam Electric, Inc. to request and receive such information. At-Will Relationship: * I understand and agree that if I am offered employment with Gilliam Electric, Inc. it will be on an “at-will” basis. This means that either I or Gilliam Electric, Inc may terminate the employment relationship at any time for any reason, with or without cause. I further understand that the “at-will” nature of my employment with Gilliam Electric, Inc. is an aspect of employment that cannot be modified or changed, except by a written agreement signed by the chief executive officer of Gilliam Electric, Inc. I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and Gilliam Electric, Inc. I agree that the below name represents my signature * Date If you are human, leave this field blank. Submit
