application

Location applied for
Position applied for
First name
Last name
Address
Address 2
City
State
Zip
Daytime Phone
Ext
Evening Phone
Other Phone
Email Address



If you are under 18, and if it is required, can you furnish a work permit?
yesno
If no, please explain
Type of employment desired
Full-TimePart-TimeTemporarySeasonalEducational Co-Op
Have you ever been employed here before?
yesno
If yes, give dates and positions
Are you able to meet the requirements of the position?
yesno
Are you legally eligible for employment in this country?
yesno
License #
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?
yesno
If yes please provide date(s) and details
ANSWERING "YES" TO THESE QUESTIONS 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 CONSIDERATION

Date available for work
Drivers license number if driving is an essential job function
What is your desired salary range?
Job 1
From

To
Employer

Telephone
Starting Job Title/Final Job title

Address
Immediate supervisor and title

May we contact for reference?
yesnoLater
Summarize nature of work performed and job responsibilities
Reason for leaving
Hourly rate/Salary

Start
Per
Final
Per
Job 2
From

To
Employer

Telephone
Starting Job Title/Final Job title

Address
Immediate supervisor and title

May we contact for reference?
yesnoLater
Summarize nature of work performed and job responsibilities
Reason for leaving
Hourly rate/Salary

Start
Per
Final
Per
Job 3
From

To
Employer

Telephone
Starting Job Title/Final Job title

Address
Immediate supervisor and title

May we contact for reference?
yesnoLater
Summarize nature of work performed and job responsibilities
Reason for leaving
Hourly rate/Salary

Start
Per
Final
Per
Job 4
From

To
Employer

Telephone
Starting Job Title/Final Job title

Address
Immediate supervisor and title

May we contact for reference?
yesnoLater
Summarize nature of work performed and job responsibilities
Reason for leaving
Hourly rate/Salary

Start
Per
Final
Per

Skills and Qualifications

Summarize any 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.

References

Job 1
First Name

Last Name

Datetime Phone

Ext

Years Known

Job 2
First Name

Last Name

Datetime Phone

Ext

Years Known

Job 3
First Name

Last Name

Datetime Phone

Ext

Years Known

Educational Background

High School

No of years completed

Did you graduate
yesno
Course of study

Trade School/Technical College


Number of hours completed

Did you graduate
yesno
Do you have your provisional?
yesno
Do you have your license?
yesno
If yes: What is your license #?

College


Number of years completed

Did you graduate
yesno
Major Degree

Course of study

Other


Number of years completed

Did you graduate
yesno
Course of study

How did you hear about Xist Fitness?

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (1) cancel further consideration of this application, or (2) immediately discharge me from the employers service whenever it is discovered.
I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.
I understand that 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 applicable local, state or federal law.
I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and 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 supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in written and signed by the employers president.
I also understand that if I am hired, I will be required to provide proof of 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.

DO NOT SUBMIT THIS FORM UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
Name*