Application for Employment

Personal Information

Full Name

Present Address

City, State, Zip

Permanent Address

City, State, Zip

Home Phone

Cell Phone

Referred by

Are you 18 years or older?

Desired Employment

Position Desired

Date Available for Work

Wages Desired

Are you currently employed?

May we contact your current employer?

Modern Shoe, Inc. may require a Background of Criminal Investigation (BCI) for employment of certain job positions.

Would you consent to a BCI?

Have you ever been convicted of a misdemeanor or a felony?

If so, state the nature of offense, when, were, and disposition:

(A conviction record will not necessarily disqualify you for employment. This information will be used only for job-related purposes and only to the extent permitted by applicable law.)

Are you prevented from lawfully becoming employed in this country because of Visa or immigration status? (Proof of citizenship or immigration status will be required upon employment.)

Education

High School (name, city, state)

Last year completed

College (name, city, state)

Last year completed

Other (specify)

Diploma or degree?

Prior Work Experience

List below your last three employers, starting with your present or most recent job.

Employer #1 (company name & phone number)

Start Date

End Date

Position

Salary (upon leaving):

Reason for leaving

Employer #2 (company name & phone number)

Start Date

End Date

Position

Salary (upon leaving):

Reason for leaving

Employer #3 (company name & phone number)

Start Date

End Date

Position

Salary (upon leaving):

Reason for leaving

References

List below 3 persons not related to you, whom you have known for at least one year.

Reference #1 (name)

Phone number

Relationship

Reference #2 (name)

Phone number

Relationship

Reference #3 (name)

Phone number

Relationship

Authorization

I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal of I have been employed, no matter when discovered by Modern Shoe, Inc.

I understand that any employment in conditioned on a background check. I authorize Modern Shoe, Inc. to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, character and general reputation to Modern Shoe, Inc. without giving me prior notice of such disclosure. In addition, I release Modern Shoe, Inc., any former employers, and all references listed above from any and all claims, demands, or liabilities arising out of or related to such investigation or disclosure.

I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be *at will* and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or Modern Shoe Inc. No promises regarding employment have been made to me and I understand that no such promise of guarantee is binding upon Modern Shoe, Inc. unless made in writing

If hired, I agree to abide by all Modern Shoe, Inc. work rules, policies, and procedures. Modern Shoe, Inc. retains the right to revise its policies or procedures, in whole or in part, at any time.

Date

Signature (please enter your full name)

Application for Employment

Personal Information

Desired Employment

Education

Prior Work Experience

References

Authorization

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