Administrative/Operational Support

Personal Information

• First Name*
• Middle Initial*
• Last Name*
• Street Address*
• City*
• State*
• Zip*
• Email*
• Phone Number (Home)*
• Phone Number (Cell)*
• Position(s) applied for*
• Referral Source (Ex.: Walk In, Employee[please provide name], Company Website, Other)
• Have you submitted an application here before?* YesNo
If yes, give date(s) and position(s):
• Have you ever been employed here before?* YesNo
If yes, give dates:
• Date Available for Work*
• Contact Information
• If necessary, Best time to Call you is?*
• Phone Number*
• Contact at Work
• May we Contact you at work? N/AYesNo
• Best Time to call you at work is
• Work Phone
• Work Permit
• If you are under 18 and it is required, can you furnish a work permit?* N/AYesNo
If no, please explain
• Are you lawfully authorized to work in the United States?* YesNo
• Have you entered into an agreement with any former employer or other party (such as non-competition agreement) that might, in any way, restrict your ability to work for our company?* YesNo
• Driver’s license number and state required if driving may be required in the job for which you are applying:*

Employment Preferences

• What is your desired salary range or rate of pay?(per hour/year)*
• Type of employment desired* Full-timePart-timeSeasonal
• Will you relocate if job requires it?* YesNo
• Will you travel if job requires it?* YesNo
• If they have been explained to you, are you able to meet the attendance requirements of the position?* N/AYesNo
• Will you work overtime if needed? YesNo
If no, please explain

Reasonable Accommodation

• Are you able to perform the “essential functions” of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.* YesNoNeed more information about the job’s 'essential functions' to respond

Criminal Background

• Have you ever pleaded “guilty” or “no contest” to or been convicted of a crime? NOTE: Answering “yes” to this question 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 account. YesNo

Employment History

Starting with your most recent employer, provide the following information.

• Employer 1
• Employer*
• Phone*
• Street Address*
• City*
• State*
• Zip*
• Date Started*
• Date Finished*
• Job Title*
• Immediate supervisor and title (for most recent position held)*
• May we contact for reference?*
• Supervisor Phone*
• Supervisor Email*
• Why did you leave?*
• Summarize the type of work performed and job responsibilities:*
• What did you like most about your position?*
• What did you like least about your position?*
• Compensation (Starting)*
• Compensation (Final)*
• Employer 2
• Employer
• Phone
• Street Address
• City
• State
• Zip
• Date Started
• Date Finished
• Job Title
• Immediate supervisor and title (for most recent position held)
• May we contact for reference?
• Supervisor Phone
• Supervisor Email
• Why did you leave?
• Summarize the type of work performed and job responsibilities:
• What did you like most about your position?
• What did you like least about your position?
• Compensation (Starting)
• Compensation (Final)
• Employer 3
• Employer
• Phone
• Street Address
• City
• State
• Zip
• Date Started
• Date Finished
• Job Title
• Immediate supervisor and title (for most recent position held)
• May we contact for reference?
• Supervisor Phone
• Supervisor Email
• Why did you leave?
• Summarize the type of work performed and job responsibilities:
• What did you like most about your position?
• What did you like least about your position?
• Compensation (Starting)
• Compensation (Final)

Skills and Qualifications

• Summarize any special training, skills, languages, licenses, bonding, certifications, and/or certificates that may assist you in performing the position for which you are applying:

• Computer Skills (include software titles and level of experience, such as basic, intermediate, or advanced.)*

Educational Background

• Educational Background
• School 1
• School*
• City & State*
• Number of Years Completed*
• Level Completed*
• GPA/Class Rank*
• Major/Minor/Certificate*
• School 2
• School
• City & State
• Number of Years Completed
• Level Completed
• GPA/Class Rank
• Major/Minor/Certificate
• References
• Reference 1
• Name*
• Title*
• Relationship to You*
• Number of Years Known*
• Phone Number*
• Email Address*
• Reference 2
• Name*
• Title*
• Relationship to You*
• Number of Years Known*
• Phone Number*
• Email Address*
• Reference 3
• Name*
• Title*
• Relationship to You*
• Number of Years Known*
• Phone Number*
• Email Address*
• Related Information

• When answering these questions, please exclude any information that would reveal race, religion, color, sex (including pregnancy), age, ancestry, national origin, disability, marital status, sexual orientation, gender identity, genetic information, or other similarly protected status.

• List special accomplishments, publications, awards, etc.*
• Is there any other job-related information you want us to know about you?*

Applicant Statement and Signature

• 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 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, résumé, 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 truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me.

• I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law.

• I understand that this application remains current for only 90 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 for me 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 with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or 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 writing and signed by the employer's president.

• I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

• I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer's affiliate(s) and third parties engaged by the employer to perform services for the employer. Any personal information shared with an affiliate or third party is to be used solely to perform the services requested by the employer.

• UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

• This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her race, religion, color, sex (including pregnancy), age, ancestry, national origin, disability, marital status, sexual orientation, gender identity, genetic information, or any other protected status under applicable federal, state, or local law.

• 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 (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

• By Checking this box I certify that I am Electronically signing this document by typing my name and dating.* I Agree
• E-Signature of Applicant*
• Date Signed*