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Employment History

(Starting with the most recent)

Employer #1

Company Name:

Phone:

Address:

Street Address City State ZIP Code

Immediate Supervisor:

Job Title:

Starting Pay Rate:

Ending Pay Rate:

Responsibilities and Duties:

Employment Dates (Month/Year):

Start

End

Reason for Leaving:

Would you like to add a second employer?*

Yes
No

Employer #2

Company Name:

Phone:

Address:

Street Address City State ZIP Code

Immediate Supervisor:

Job Title:

Starting Pay Rate:

Ending Pay Rate:

Responsibilities and Duties:

Employment Dates (Month/Year):

Start

End

Reason for Leaving:

Would you like to add a third employer?*

Yes
No

Employer #3

Company Name:

Phone:

Address:

Street Address City State ZIP Code

Immediate Supervisor:

Job Title:

Starting Pay Rate:

Ending Pay Rate:

Responsibilities and Duties:

Employment Dates (Month/Year):

Start

End

Reason for Leaving:

References

LIST INDIVIDUALS WHO ARE WELL-ACQUAINTED WITH YOUR QUALIFICATIONS. DO NOT LIST RELATIVES, FORMER EMPOYEES OR SUPERVISORS.

Name	Title	Address	Phone Number

Use the + icon to the right to add a new row. You can add up to four references.

Applicant Statement

I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE, TO THE BEST OF MY KNOWLEDGE. AND I UNDERSTAND THAT ANY MISREPRESENTATION OR WILLFUL OMISSION OF FACTS IS SUFFICIENT REASON FOR REJECTION OF MY APPLICATION OR TERMINATION OF MY EMPLOYMENT.

I HEREBY AGREE AND AUTHORIZE THE COMPANY TO DEDUCT, WITHHOLD, OR DIVERT FROM MY WAGES ANY AMOUNTS NECESSARY TO OFFSET ANY DAMAGES CAUSED BY ME OR THE VALUE OF ANY PROPERTY OR MONEY ENTRUSTED TO ME BY OR OWED BY ME TO THE COMPANY DURING THE COURSE OF MY EMPLOYMENT WITH THE COMPANY, PROVIDED THAT IT DOES NOT CAUSE ME TO RECEIVE LESS THAN THE MINIMUM HOURLY WAGE REQUIRED BY STATE AND FEDERAL LAWS.

I AGREE THAT I WILL SETTLE ANY AND ALL PREVIOUSLY UNASSERTED CLAIMS, DISPUTES, OR CONTROVERSIES ARISING OUT OF OR RELATING TO MY APPLICATION FOR CANDIDACY FOR EMPLOYMENT, EMPLOYMENT, AND/OR CESSATION OF EMPLOYMENT WITH THE COMPANY BY FINAL AND BINDING ARBITRATION BEFORE A NEUTRAL ARBITRATOR. BY WAY OF EXAMPLE ONLY, SUCH CLAIMS INCLUDE CLAIMS UNDER FEDERAL, STATE, AND LOCAL STATUTORY OR COMMON LAW, SUCH AS AGE DISCRIMINATION IN EMPLOYMENT ACT, TITLE VII OF THE CIVIL RIGHTS ACT OF 1964, AS AMENDED, INCLUDING THE AMENDMENTS OF THE CIVIL RIGHTS ACT OF 1991, THE AMERICANS WITH DISABILITIES ACT, THE LAW OF CONTRACT, AND THE LAW OF TORT.

I HEREBY CERTIFY THAT, IF EMPLOYED, I WILL REPORT TO MY SUPERVISOR OR OTHER MEMBER OF MANAGEMENT, IF I AM EVER HARASSED BY SOMEONE IN THE COMPANY OR IF I EVER BECOME AWARE OF ANY UNETHICAL BEHAVIOR BY ANY EMPLOYEE.

I EXPRESSLY UNDERSTAND AND AGREE THAT, IF EMPLOYED, MY EMPLOYMENT, HAVING NO SPECIFIED TERM, IS BASED UPON MUTUAL CONSENT AND MAY BE TERMINATED AT WILL, WITH OR WITHOUT CAUSE, BY EITHER PARTY (COMPANY OR ME) WITHOUT PRIOR NOTICE TO THE OTHER. I UNDERSTAND THAT IF I WANT TO LEAVE IN GOOD STANDING, I WILL PROVIDE TWO WEEKS’ NOTICE TO MY SUPERVISOR BEFORE TERMINATING MY EMPLOYMENT.

MY SIGNATURE IS EVIDENCE THAT I HAVE READ AND AGREE WITH THE ABOVE STATEMENTS.

Consent to provide employment history to prospective employer

Authorized by LB 959 - Legislative Bill 959 download

I hereby give consent to any and all of my prior employers to provide information with regard to my employment with my prior employers to the Company (prospective employer).

I consent to the disclosure of the following information about me by any and all of my prior employers:

Date and duration of employment;
Pay rate and wage history on the date of receipt of this written consent;
Job description and duties;
The most recent written performance evaluation prepared prior to the date of the request for information and provided to me during the course of my employment;
Attendance information;
Results of drug or alcohol tests administered within one year prior to the request for information;
Threats of violence, harassing acts, or threatening behavior related to the workplace or directed at another employee;
Whether I was voluntarily or involuntarily separated from employment and the reasons for the separation; and
Whether I am eligible for rehire.

The consent is valid for six months from the date of my signature below.

Signature of Applicant:

Date*

Application for Employment

Step 1 of 2

APPLICANT INFORMATION

JOB INTEREST

GENERAL INFORMATION

Employment History

Employer #1

Employer #2

Employer #3

References

Applicant Statement

Consent to provide employment history to prospective employer