Application For Employment
(An Equal Opportunity Employer)
Personal Information
Name:
Date:
Last
First
Middle
SSN
:
Present Address:
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Street
City
State
ZIP
Years at this Address
Previous Address:
(If less than two years at present address)
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Street
City
State
ZIP
Years at this Address
Home Phone#:
Are you 18 years or older?
no
yes
Cell Phone#:
E-Mail Address:
Are you either a U.S. citizen or an alien authorized to work in the United States?
no
yes
Employment Desired
Any
Web Developer
Member Service
Mobile Application Developer
Graphic Designer
Inside Sales Rep
AVL Sales and Design
Position:
Desired Location
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Date you can start?
Salary desired
Are you employed now?
no
yes
If so, may we inquire of your present employer?
no
yes
Ever applied to this company before?
no
yes
Where?
When?
Referred by:
Education
Name & Location of School
*
Number of Years Attended
Graduated? (Y/N)
Degree, Diploma, or Certificate Received
High School
College
Other Education
General
Areas of special study or research work:
Special skills:
Activities (Civic, Athletic, etc.):
Exclude organizations, the name of which indicates the race, creed, sex, age, marital status, color or nation of origin of its members.
U.S. Military:
Rank:
Present Membership in National Guard or Reserves:
Former Employers
(List below at least three employers, starting with last one first.)
Date
Month & Year
Name & Address of Employer
Salary
Position
Reason for Leaving
From:
To:
From:
To:
From:
To:
Criminal Record
(Note: A guilty plea to or conviction of a crime, or a pending charge, is not an automatic bar to employment; all circumstances will be considered.
Please list ALL convictions or charges
)
Have you ever pled guilty to, or been convicted of, a crime(yes or no)?
If so, state the nature of the crime(s):
Date of plea(s) or conviction(s):
Name and location of the court(s):
Do you have any criminal charges pending against you(yes or no)?
If so, state the nature of the crime(s) you are alleged to have committed:
Name and location of court(s) where pending:
References
Please provide 3 references (at least 2 professional) not realated to you.
Name
Address
Business
Phone Number
Years Acquainted
It is unlawful in the states of Maryland and Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal pentalties and civil liability.
In case of emergency, notify:
Name
Address
Phone Number
"I certify that the information contained in this application is correct to the best of my knowledge and understand that, if employed, falsified statements on this application will be grounds for dismissal.
I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same to you. I authorize you to request and receive such information.
In consideration for my employment and my being considered for employment by your company, I agree to adhere to the rules and regulations of the company and hereby acknowledge that these rules and regulations may be changed by your company at any time, at the company's sole option and without any prior notice. In addition, I acknowledge that my employment may be terminated, and any offer of employment, if such is made, my be withdrawn with or without prior notice, any any time, at the option of either the company or me."
I hereby acknowledge that I have been advised that this application will remain active for no more than 90 days from the date it was signed."
I agree.
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