Which position are you applying for?
Name
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First Name
Last Name
Email
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Phone
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(###)
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Current Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name of Employer
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Address of Employer
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Starting Date of Employment
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MM
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YYYY
Ending Date of Employment
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Put today's date if you are currently employed.
MM
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Supervisor Name
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First Name
Last Name
Supervisor Title
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May we contact this employer?
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Yes
No
Job Title and Duties
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Reason for Leaving
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Name of Employer
Address of Employer
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Starting Date of Employment
MM
DD
YYYY
Ending Date of Employment
MM
DD
YYYY
Supervisor Name
First Name
Last Name
Supervisor Title
May we contact this employer?
Yes
No
Job Title and Duties
Reason for Leaving
Have you ever been involuntarily terminated or asked to resign from any job?
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Yes
No
If yes, please explain:
Please explain any gaps in your employment history:
Please list any other experience, job related skills, additional languages, or other qualifications that you believe should be considered in evaluating your qualifications for employment:
High School
Did you receive a diploma?
Yes
No
College/University
Degree Acquired
Yes
No
Describe course of study or major:
Graduate/Professional
Please describe any additional trade, correspondence, or similar schools you have attended or training you have received:
Please list three professional references of individuals who are not related to you:
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Please include: Name, title, business relationship, and phone number.
Please list three people you have worked with who know you well; do not include personal friends or relatives:
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Please include: Name, occupation, relationship (Example: worked together at ABC Company for 3 years), years acquainted, and phone number.
Have you ever used another name?
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Yes
No
Is any additional information relative to name changes, use of an assumed name, or nickname necessary to enable a check on your work and educational record?
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Yes
No
If "yes" to the preceding two questions, please explain:
Have you ever worked for this organization before?
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Yes
No
If yes, please give dates and position:
Do you have friends and/or relatives working for this company?
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Yes
No
If yes, name(s) and relationship(s):
On what date are you available to begin work?
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MM
DD
YYYY
Days/Hours available to work:
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Are you available to work:
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If hired, would you have a reliable means of transportation to and from work?
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Yes
No
Can you travel if the position requires it?
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Yes
No
If hired, can you present evidence of your identity and legal right to live and work in this country?
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Yes
No
Briefly state your personal testimony. Please include when and the circumstances surrounding your decision to commit your life to Jesus Christ:
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What is the main reason that you are seeking employment with the Mission?
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List any special gifts, training, or interests that you feel may be useful at the Mission:
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Church background:
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Please include church name, address, length of attendance, and any ministries in which you are involved.
List the names and addresses of a ministry leader at your church and one other person who is not related to you who know you personally and have definite knowledge of your character:
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Please comment freely here regarding Visalia Rescue Mission's Statement of Faith:
_____ I hereby authorize the Company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the prior employers and references I have listed to disclose to the Company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
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I give consent
I do not give consent
_____ In the event of my employment with the Company, I understand that I am required to comply with all rules and regulations of the Company. I understand that the Company reserves the right to require me to submit to a test for the presence of drugs or alcohol in my system prior to employment and at any time during my employment, to the extent permitted by law. I voluntarily submit to the drug and/or alcohol screening and understand that the presence of drugs or alcohol in my system may disqualify me from further consideration of employment with this company, or may result in termination of my employment with the company.
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I give consent
I do not give consent
_____ I understand that any offer of employment may be contingent upon the passing of a physical examination. I consent to the disclosure of the results of the physical examination and related tests to the Company. I understand that should I decline to sign this consent or take any of the above tests, my application for employment may be rejected. I understand that bonding may be a condition of hire. If it is, I will be so advised either before or after hiring and a bond application will have to be completed.
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I give consent
I do not give consent
_____ I understand that I may be required to take other tests such as personality and honesty tests, prior to and during my employment. I understand that should I decline to sign this consent or take any of the above tests, my application for employment may be rejected or my employment may be terminated.
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I give consent
I do not give consent
_____ If hired, I understand and agree that my employment with the Company is at-will, and that neither I, nor the Company is committed to continuing the employment relationship for any specific term. I further understand that the Company or I may terminate the employment relationship at any time, with or without cause, and with or without notice. I understand that the at-will status of my employment cannot be amended, modified, or altered in any way by oral statements or in any other way, but can only be altered by written amendment signed by the Owner/President of this Company.
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I give consent
I do not give consent
_____ I understand that safety of employees is extremely important to the Company and that the Company is committed to ensuring a safe working environment. I understand that I, and every employee, have a responsibility to prevent accidents and injuries by observing all safety procedures and guidelines and following the directions of my site supervisor. I understand and agree to comply with federal, state, and local regulations related to on-the-job safety and health. I also recognize that an effective safety program extends beyond normal working hours. Safety should be promoted within the family and in off-the-job activities. I understand and agree to adhere to safety practices while performing my job. A copy of the Injury and Illness Prevention Plan will be provided to me upon my request.
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I give consent
I do not give consent
_____ I understand that my employment will be contingent upon signing the Company’s Alternative Dispute Resolution Agreement (if applicable), a copy of which will be provided with the Employee Handbook packet.
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I give consent
I do not give consent
_____ I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge.
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I give consent
I do not give consent
_____I hereby certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
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I give consent
I do not give consent
_____ I understand that if I am selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard.
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I give consent
I do not give consent
_____I understand It is my responsibility to verify that the state and federal payroll tax deductions taken on my payroll checks match the information I provided on my completed W-4 form.
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I give consent
I do not give consent
_____ I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed and the remainder of this Agreement shall be enforceable.
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I give consent
I do not give consent
Signature Area
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