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Date of Application
000-000-0000 or (000) 000-0000
$xx per hour
Do you have any physical, mental, or medical impairment that would interfere with your ability to perform the essential duties of this job with or without an accommodation? If “Yes”, please describe in full. (Refer to position description if necessary)
Verification and completion of Form I-9 must be submitted no later than 3 business days after date of hire
Start Date
End Date
Have you ever been counseled or disciplined for cash handling violations?
Have you ever been counseled, disciplined or terminated for theft, violence, discrimination, or harassment?
Within the past 10 years, have you ever been convicted of a felony, entered a plea of nolo to a felony charge or been convicted of a misdemeanor?
* A yes answer does not automatically disqualify you for employment. All individual circumstances may be considered.
I authorize investigation of all statements and references contained in this employment application as may be necessary in arriving at an employment decision, including requests for criminal or credit reports. I understand that incorrect, misleading, falsified or omission of information on this application may result in disqualification from consideration of employment or immediate termination of employment. I understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs during employment.
