Work at Clifford-Jacobs

Application for Employment

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Position Applied For:

Date of Application:

Referral Source

First Name

Last Name

Email Address

Address

City

State / Province

Postal Code

Contact Number

Alternate Contact Number

Upload Resume

Please upload your Resume in PDF format.

If necessary, best time to call you at home is (Specify Time in AM / PM)

May we contact you at work?

Yes No

If you are under 18 and it is required, can you furnish a work permit?

Yes No N/A

Have you submitted an application here before?

Yes No

Have you ever been employed here before?

Yes No

Are you legally eligible for employment in this country?

Yes No

Date available for work

Type of employment desired

Full Time Part Time Temporary Seasonal Educational Co-Op

Will you relocate if the job requires it?

Yes No

Will you travel if the job requires it?

Yes No

Are you able to meet the attendance requirements of the position?

Yes No

Will you work overtime if required?

Yes No

Have you ever been bonded?

Yes No

Driver's license number if applicable

State / Province of Issue

Employment History

Provide the following information for your past and current employers, assignments or volunteer activities, starting with the most recent (use additional sheets if necessary). Explain any gaps in employment in comments section below.

Employer

Address

Job Title

Supervisor & Title

Reason for Leaving

May we contact for reference?

Yes No

Start Date

End Date

Starting Hourly Rate / Salary

Final Hourly Rate / Salary

Summarize the type of work performed and job responsibilities

Add Another Employer

Yes No

Additional Employment Details

Comments (including explanation of any gaps in employment)

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

Educational Background

School

Number of Years Completed

GPA / Class Rank

Degree / Diploma

Minor

Major

Add Another School

Yes No

References

List names and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

Reference 1

Telephone

Years Known

Reference 2

Telephone

Years Known

Reference 3

Telephone

Years Known

Additional Information

List professional, trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or any other similarly protected status.)

List special accomplishments, publications, awards, etc. (Exclude anything which would reveal sex, race, religion, national origin, age, color, disability or any other similarly protected status.)

List any additional information you would like us to consider.

Terms of Acceptance

I, the applicant, warrant the truthfulness of the information provided in this application. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the below Terms of Acceptance.

I understand that if I am employed, any misrepresentation or material omission made by me 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 a 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.

FORGING PARTNERSHIPS OF VALUE SINCE 1919

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