First Name* Last Name* Middle Initial

Address*

City* State* Zip*

Daytime Phone* Evening Phone

Position(s) Applied For*

If you are under 18, and it is required, can you furnish a work permit? Choose One YES NO
If NO, please explain.

Have you ever been employed here before? * Choose One YES NO

Are you legally eligible for employment in this county? * Choose One YES NO

Date available to work.

Type of employment desired. Choose One Full Time Part Time Temporary Seasonal Educational Co-Op

Are you able to meet the attendance requirements of the position? * Choose One YES NO

Have you been convicted of a crime in the last seven years? * Choose One YES NO
If YES, please explain.

Driver's license number if driving is an essential job function.



EMPLOYMENT HISTORY

Please Provide the following information for your past three employers, assignments or volunteer activities, starting with the most recent.

From To Job Title

Employer Phone Address

Supervisor Title

Reason for Leaving

Hourly Rate/Salary Starting Final

Briefly explain the nature of work performed and job responsibilities.

From To Job Title

Employer Phone Address

Supervisor Title

Reason for Leaving

Hourly Rate/Salary Starting Final

Briefly explain the nature of work performed and job responsibilities.

From To Job Title

Employer Phone Address

Supervisor Title

Reason for Leaving

Hourly Rate/Salary Starting Final

Briefly explain the nature of work performed and job responsibilities.




SKILLS AND QUALIFICATIONS

Summarize any training, skills, licenses, and/or certifications that may qualify you as being able to perform job-related functions for which you are applying.

EDUCATIONAL BACKGROUND

High School Years Completed

Did You Graduate? Choose One YES NO Course of Study

College Years Completed

Degree Choose One YES NO Major

Other Years Completed

Did You Graduate? Choose One YES NO Course of Study



REFERENCES

Name* Phone* Years Known*

Name* Phone* Years Known*

Name* Phone* Years Known*



READ CAREFULLY BEFORE SIGNING

I agree that any claim or lawsuit relating to my service with Goldsmith & Eggleton, Inc., must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit. I waive any statute of limitations to the contrary. I understand that if I am hired, this becomes part of my official employment record.

I understand that if I am employed, any misrepresentation or material omission made on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer's service, whenever it is discovered.

I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information.
The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer.

I understand it is this company's policy not to refuse to hire 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 hired, I will be required to provide proof of identity and legal work authorization.

* Choose One I Agree I Do NOT Agree

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

* Choose One YES NO

Date*

Goldsmith & Eggleton is an equal opportunity employer. Screening test for alcohol and illegal drug use may be required before hiring and during your employment here.