Application For Employment

Personal Information

Name

First Middle Last

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Cell

Email

Employment Desired

Position

Salary Desired

Date You Can Start

Have You Applied Here Before?

Yes
No

Have You Worked Here Before?

Yes
No

When?

Are You Employed Now?

Yes
No

Where?

May We Contact Them?

Are You Available to Work?

Full Time
Part Time
Temporary

Education History

School

Name and Location of School

Did you Graduate

Yes
No

Subjects Studied

Former Employers

(List below your last four employers, starting with the last one first)

Employed From:

Employed To:

Name and Address of Employer

Salary

Position

May We Contact Them?

Yes
No

Reason for leaving:

Employed From:

Employed To:

Name and Address of Employer

Salary

Position

May We Contact Them?

Yes
No

Reason for leaving:

Employed From:

Employed To:

Name and Address of Employer

Salary

Position

May We Contact Them?

Yes
No

Reason for leaving:

Employed From:

Employed To:

Name and Address of Employer

Salary

Position

May We Contact Them?

Yes
No

Reason for leaving:

Prior Military Service

Did you serve in the U.S. Armed Forces?

Yes
No

Branch of the Military

Rank

Job

From:

To:

Professional References

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region

Phone

Years Known

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region

Phone

Years Known

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region

Phone

Years Known

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region

Phone

Years Known

Drivers License

Do You Have a Valid Drivers License?

Yes
No

Drivers License #

State

Expiration Date

Do You Have a Valid CDL?

Yes
No

State

Expiration Date

History

Have You Ever Been Convitcted of a Felony?

Yes
No

Felony

County & State

Date of Conviction

An Application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

certify*

I certify that the facts contained in this application are true and complete to the best of my knowledge. Should UMD Automated Systems employ me; any false or misleading information will result in my employment being immediately terminated. I authorize investigation of all statements contained in this application and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, to arrive at an employment decision. I hereby release UMD Automated Systems and any former employer and any third party from any liability whatsoever that may be imposed as a result of the release of such information. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws. I hereby understand and acknowledge that any employment relationship with UMD Automated Systems is of an "At-Will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time, with or without notice, with or without cause. It is further understood that this "At-Will" employment relationship may not be changed by any written document or by verbal agreement unless an authorized Executive of the Company specifically acknowledges such change in writing.*

Signature*

Date*

Application for Employment

Personal Information

Employment Desired

Education History

Former Employers

Prior Military Service

Professional References

Drivers License

History

Title