Application for Employment Company Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodations to the application and/or interview process should notify a representative of the Human Resources Department. Position(s) applied for Date of application Full Name Last, First and Middle Address Street, City, State and ZIP Code Phone Number Email Address Reference Source How did you hear about us? If you are under 18 and it is required, can you furnish a work permit? Yes No If no, please explain: Have you ever been employed here before? Yes No If yes, give dates and positions: Are you legally eligible for employment in this country? Yes No Date available for work: What is your desired salary range? Type of employment desired: Full-Time Part-Time Temporary Seasonal Educational Co-Op Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)? Yes No Need more information about the job's "essential functions" to respond. This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law. Driver's license number required if driving may be required in the job for which you are applying: State driver's license was issued: Have you ever pleaded Yes No If yes, please provide dates and details: Answering "yes" to this question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. NOTE: You are not obligated to disclose the existence of any conviction or arrest records which have been sealed, or expunged pursuant to Chapter 20, Section 2630/12 of the IL Compiled Statutes. Employment History 1 Starting with your most recent employer, provide the following information: Employer #1 Name: Employer #1 Telephone Number Employer #1 Address Street, City, State and ZIP Code Employer #1 Dates of Employment Month/Year to Month/Year Employer #1 Job Title Employer #1 Starting Compensation Please provide amount and if salary or hourly pay. Employer #1 Final Compensation Please provide amount and if salary or hourly pay. Employer #1 Immediate Supervisor and Title (for most recent position held) Please provide name and title. May we contact them for reference? Yes No Later Why did you leave? Summarize the type of work performed and job responsibilities. Employment History 2 Starting with your second most recent employer, provide the following information: Employer #2 Name: Employer #2 Telephone Number Employer #2 Address Street, City, State and ZIP Code Employer #2 Dates of Employment Month/Year to Month/Year Employer #2 Job Title Employer #2 Starting Compensation Please provide amount and if salary or hourly pay. Employer #2 Final Compensation Please provide amount and if salary or hourly pay. Employer #2 Immediate Supervisor and Title (for most recent position held) Please provide name and title. May we contact them for reference? Yes No Later Why did you leave? Summarize the type of work performed and job responsibilities. Employment History 3 Starting with your third most recent employer, provide the following information: Employer #3 Name: Employer #3 Telephone Number Employer #3 Address Street, City, State and ZIP Code Employer #3 Dates of Employment Month/Year to Month/Year Employer #3 Job Title Employer #3 Starting Compensation Please provide amount and if salary or hourly pay. Employer #3 Final Compensation Please provide amount and if salary or hourly pay. Employer #3 Immediate Supervisor and Title (for most recent position held) Please provide name and title. May we contact them for reference? Yes No Later Why did you leave? Summarize the type of work performed and job responsibilities. AN EQUAL OPPORTUNITY EMPLOYER
