AFM - Arthur F. Mulligan, Inc.

For use in all states EXCEPT MA, MD, MT, ND, OR, RI, SD, and WA	Date:
		MM / DD / YYYY

APPLICATION FOR EMPLOYMENT

We are committed to policy of Equal Employment Opportunity and will not discriminate on any legally recognized basis, including, but not limited to, race, age, color, region, sex, national origin, citizenship, ancestry, physical or mental disability, veteran status or any other basis recognized by federal, state or local law.

PERSONAL BACKGROUND

Name:
	Last	First	Middle

Phone:

Cell Phone:

Present Address:
	Street	City	State	Zip

Full Time:

Part Time :

Specify Hours :

Salary Desired :

Is there any reason we may not inquire of your present employer or prior employer?
If yes, please explain below:

Have you ever applied to this company before?
		Where?	Year?

Are you willing to work overtime?

If driving is a requirement of the job for which you are applying, do you have a valid driver’s license?

If a minor, can you produce the work certificate necessary to obtain employment?

Are you able, at the time of employment, to submit verification of your legal right to work in the U.S.? (Verification and completion of Form 1-9 must be submitted no later than 3 business days after date of hire)

Have you ever been convicted of a felony which is substantially related to the functions or qualifications of the position(s)) for which you are applying?

(Note: This question does not apply to convictions which have been expunged, sealed, pardoned or otherwise exonerated or eradicated. A conviction record will not necessarily be a bar to employment)

If yes, please describe fully the criminal conviction(s), listing the nature of the offense(s), listing the nature of the offense(s) and your rehabilitation since the convictions(s).

EDUCATION BACKGROUND

Education	Name/Address of School	Highest Grade	Area of Study
High School
College(s)
Trade, Business or Graduate

Specialized technical skills (e.g. computer program, language software, equipment operation, special tools or machines). If none, please state.

WORK EXPERIENCE (Please list your last four employers, starting with your present or last place of employment)

Dates Employed (MM/YYYY)	Name, Address and Phone Number of Employer	Salary	Job Title	Name of Supervisor	Reason you left

From:
To:

From:
To:

From:
To:

From:
To:

REFERENCES Please provide the names of three additional work-related references whom we may call. Do not list relatives. Individuals with no prior work experience may list school or volunteer-related references.

	Name & Position	Company	Phone Number

1

2

3

APPLICANT CERTIFICATION— PLEASE READ CAREFULLY
I understand that this application is not a contract, offer or promise of employment. I acknowledge that employment with the company is on an employment at will basis. This means my employment with the company can be terminated at any time, with or without cause or advance notice and acceptance of employment is not a contract of employment for any specified time. Similarly I am free to terminate my employment with the company at any time for any reason. This at-will provision may be modified or waived only by a written agreement signed by the company’s president and me.

I further understand that I am responsible for being familiar with the Company’s policies, rules and regulations, and I understand that the company has complete discretion to modify its policies, rules, regulations and practices at any time, to the extent permitted by federal, state and local law, except that it will not modify its policy of employment at will. By my continued employment with the Company, I consent to any such changes.

I certify that the above information is complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation or omission of information on this form or relation to my application of employment may result in my denial of employment, or if employed, my immediate dismissal.

I hereby authorize the company or its agents to confirm all statements contained in this application and/or resume to the extent permitted by federal, state or local law and I agree to complete any requisite authorization forms.* I release all parties from any liability arising out of this provision and the use of such information.

Applicant’s Signature:

Date: