Job Application Application for Employment Candidate's Name* Date* Your Email* Address* Telephone Number* Are you 18 years of age or older?*---YesNo Are you either a U.S. citizen or an alien authorized to work in the U.S.?*---YesNo Have you ever worked or attended school under another name? If so, under what name? Position Desired Position Desired* Start Date Available* Wage Rate Desired* Wage Frequency*---HourlyMonthlyAnnually Do you prefer part-time or full-time?*---Full-timePart-time If part-time, hours per week desired:* Hours you are available to work:* Days of week you are available to work:* Are you able to work:WeekendsHolidaysNightsOvertime Have you previously worked for InterCambio Express Inc.?*---NoYes Start date of previous employment with InterCambio Express Inc.* End date of previous employment with InterCambio Express Inc.* Reason(s) for leaving* Former supervisor(s) at this company:* How did you learn about this opening?* Education High School Graduated?---YesNo Course of Study Technical School: Graduated?---YesNo Course of Study: College/University: Graduated?---YesNo Course of Study: Post-Graduate Education: Graduated?---YesNo Course of Study: Other education, training or special skills: Skills Typing Speed (WPM):* Are you experienced in using personal computers?*---NoYes Type of computer:*---PCMAC Work Experience Please list all previous employment, beginning with the most recent. Employer Address Start Date End Date Position Held Reason for Leaving Supervisor's Name & Title: May we contact them?---YesNo Description of Duties: Starting Compensation Final Compensation Add another employer?NoYes Second Employer Employer Address Start Date End Date Position Held Reason for Leaving Supervisor's Name & Title: May we contact them?---YesNo Description of Duties: Starting Compensation Final Compensation Add another employer?NoYes Third Employer Employer Address Start Date End Date Position Held Reason for Leaving Supervisor's Name & Title: May we contact them?---YesNo Description of Duties: Starting Compensation Final Compensation Add another employer?NoYes Fourth Employer Employer Address Start Date End Date Position Held Reason for Leaving Supervisor's Name & Title: May we contact them?---YesNo Description of Duties: Starting Compensation Final Compensation References Identify two persons who know your work, beginning with the most recent. Reference 1: Name* Phone Number* Email* Address* City* State* ZIP* Position or Title* Years Known* Reference 2: Name* Phone Number* Email* Address* City* State* ZIP* Position or Title* Years Known* Authorization and Acknowledgements: I affirm that the information I have provided in this application is true to the best of my knowledge, information and belief, and I have not knowingly withheld any information requested. I understand that withholding or misstating any information requested in this application is grounds for rejection of my application, and that providing false or misleading information in this application is grounds for discharge.I authorize the company to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure. Candidate's Signature* Date* Δ
