Application for Employment

Application For Employment

Ameridial is an equal opportunity employer. This application will not be used for limiting or excluding any application for consideration of employment based on any prohibited state or federal law.Applicants requiring a reasonable accommodation in completing this application should notify company representative.

Field Descriptions in Blue are Required.

Select Preferred Location: Select Preferred Shift:
Select Alternate Location: Ad Number (Leave as GEN if unknown):
How Did You Hear About Us? Name of Source:
Employee Reference - Referred By: Referred Employee #
First Name: Middle Name: Last Name:
Address:
City: State: Zip:

Previous Address (if less than 2 years at current address):
City: State: Zip:

Primary Phone: Secondary Phone: E-mail:
Are you willing to receive text alerts for employment opportunities?
Are you willing to receive email alerts for employment opportunities?
If hired, would you be willing to submit and pass a background screening?
Have you been convicted of a felony within the last 7 years? **
If hired, would you be able to present evidence of U.S. Citizenship or proof of your legal right to work in the U.S.?
If hired, do you have transportation to/from work?

Employment Desired:

Position: Date You Can Start MM/DD/YYYY: Salary Desired:
Are You Employed Now? If so, may we inquire with your present employer?
If you are NOT currently employed, Are you currently laid off?
Have you ever worked for Ameridial or Donor Care Center? If so, What Location?:

Education:

Education Name and Location # of Years Attended Did you Graduate? Subjects Studied
High School
GED or Equivalent
College
Trade School

General:

Subjects of special study or research work:
Do you speak /write any foreign language? If so, what language?

Former Employers: (list in order starting with the present)

Check here if you have NO previous work experience (If unchecked at least one entry is required)
Start Date MM/YYYY End Date MM/YYYY Name and Location Phone Number (No Dashes) Salary Position Reason for Leaving

References:

Name Address Phone Number (No Dashes) Occupation Years Known

In Case of Emergency Notify:

Name:
Address:
Phone:
Comments: Anything additional you would like to add (200 Characters or less):
Please read carefully before submitting your application
I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission, including any misstatement of material fact on this application or any reference or document secured can be used as a grounds for rejection of my application for employment or, if employed, terms for my immediate termination from employment.

I understand that if I am employed, my employment can be terminated at any time with or without prior notice by either me or the company.

I permit the company to examine my references, records of employment, education records and any other information that I have provided. I authorize references that I have submitted to disclose any information related to my work record and my professional experiences with them without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons, corporations, partnerships and associations from any & all claims, demands, liabilities arising out of or in any way to such examination or revelation.