Location:   Santa Ana   Palm Desert

Employment Application
An Equal Opportunity Employer
Date Last Name First Name Middle
Present Address
No. & Street City State Zip
Permanent Address (if different from present address)
No. & Street City State Zip
Cell-Phone Home Phone Email

Employment Desired
Position applying for:  
Are you applying for:
Regular full-time work? Yes No
Regular part-time work? Yes No
Temporary work, e.g., summer or holiday work? Yes No
What days and hours are you available for work?
If applying for temporary work, during what peroid of time will you be available?
From:   To:
Are you available for work on weekends? Yes No
Would you be available ro work overtime, if necessary? Yes No
If hired, on what date can you start work?
Salary desired:
How did you hear of this position?:
If referred, please note the name of the person that referred you to us:

Personal Information
Have you ever applied to or worked for The Company before? Yes No
If yes, when?
Do you have any friends or relatives working for The Company? Yes No
If yes, state name(s) and relationship:
Name Relationship
Name Relationship
Why are you applying for work at The Company?
If hired, would you have a reliable means of transportation to and from work? Yes No
Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.) Yes No
If hired, can you present evidence of your U.S. citizenship or proof of your legal to live and work in this country? Yes No
Are you able to perform the essential functions of the job for which you re applying, either with or without reasonable accomodation? Yes No
If no, describe the functions that cannot be performed.
(Note: We comply with the ADA and consider reasonable accomodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)
Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (Convictions for marijuana-relted offenses that are more than two years old need not be listed.) Yes No
If yes, state nature of the crime(s), when and where convicted, and disposition of the case.
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
Are you currently employed? Yes No
If so, may we contact your current employer? Yes No

Education, Training, and Experience
School Name and Address No. of Years Completed Did you Graduate? Degree or Diploma
High School
City State Zip
Yes No
College/ University
City State Zip
Yes No
Vocational/ Business
City State Zip
Yes No
Health Care Training
City State Zip
Yes No
Many of our customer (clients) do not speak English. Do you speak, write or understand any foreign languages? Yes No
If yes, which language(s)?
Do you have any other experience, training, qualifications, or skills that you feel make you especially suited for work at The Company? Yes No
If so, please explain:

Answer the following questions if you are applying for a professional position:
Are you licensed/certified for the job applied for? Yes No
Name of license/certification:   Issuing state:
License/certification number:
Has your license/certification ever been revoked or suspended? Yes No
If yes, state reason(s), date of revocation or suspension, and date of reinstatement.

Employment History
List below all present and past employment starting with your most recent employer (last five years is sufficient). Acount for all periods of unemployment. You must complete this section even if attaching a resume.
Name of Employer Telephone No.
Type of Business Your Supervisor's Name
Address & Street City State Zip
Date of Employment: Weekly Pay:
From To Starting Ending
Your Position and Duties
Reason for Leaving
May we contact this employer for a reference? Yes No
Add Employment History

Military Service
Have you obtained any special skills or abilities as the result of service in the military? Yes No
If so, describe:

List below three persons not related to you who have knowledge of your work performance within the last three years. Include at least one direct manager.
First Name Last Name Telephone No.
Address & Street City State Zip
Occupation No. of Years Acquainted

First Name Last Name Telephone No.
Address & Street City State Zip
Occupation No. of Years Acquainted

First Name Last Name Telephone No.
Address & Street City State Zip
Occupation No. of Years Acquainted

Please Read Carefully, Initial Each Paragraph and Sign Below
Initials I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
Initials I hereby authorize The Company to thoroughly investigate my references, work record, educaion and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnership and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
Initials I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company's designated representative.
Initials Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien or outstanding judgement) be conducted by internal personnel employed by the Company, I am entitled to compies of any such public records obtained by the Company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.
I waive receipt of a copy of any public record described in the paragraph above.


Applicant's Signature: (This is a digital signature)
Clear Signature