Employment Application

Name *

Instructions to applicant: Please answer all questions. If the answer to any question is "no" or "none", do not leave it blank, write "no" or "none" in the space.

First Name

Last Name

What Position are you applying for? *

Date *

Home Phone Number

ext.

Cell Phone Number *

ext.

Emergency Contact Phone Number

ext.

Contact Name and Relationship

Email Address *

Have you ever worked for Mercer before? *

Are you over age 18? *

Date available to start *

Are you a citizen of the United States?

If not, do you have work papers?

Type of Employment desired *

Have you ever pled "guilty" or "no contest" to or been convicted of a crime? *

If yes, give dates and details

Referred by

Driver License # If applicable to position

State Issued

Expiration Date

Current and Three Years Previous Addresses

Current Address *


Street

Apt# / PO Box

City

State	Postal Code

Address 1


Street

Apt# / PO Box

City

State	Postal Code

Address 2


Street

Apt# / PO Box

City

State	Postal Code

Address 3


Street

Apt# / PO Box

City

State	Postal Code

Education

Please circle the highest grade completed

High School Graduate (or equivalent) *

College

Field of Study and Degree Earned

Work History

Give a complete work history for the past THREE years, including any unemployment or self-employment and provide W-2 or 1099, for any out of business companies. Begin with the most recent job.

Last Employment

Start Date

End Date

Company Name

Company Address


Street

Apt# / PO Box

City

State	Postal Code

Company Phone Number

ext.

Position Held

Reason for Leaving

Previous Employment 1

Start Date

End Date

Company Name

Company Address


Street

Apt# / PO Box

City

State	Postal Code

Company Phone Number

ext.

Position Held

Reason for Leaving

Previous Employment 2

Start Date

End Date

Company Name

Company Address


Street

Apt# / PO Box

City

State	Postal Code

Company Phone Number

ext.

Position Held

Reason for Leaving

Previous Employment 3

Start Date

End Date

Company Name

Company Address


Street

Apt# / PO Box

City

State	Postal Code

Company Phone Number

ext.

Position Held

Reason for Leaving

Previous Employment 4

Start Date

End Date

Company Name

Company Address


Street

Apt# / PO Box

City

State	Postal Code

Company Phone Number

ext.

Position Held

Reason for Leaving

Previous Employment 5

Start Date

End Date

Company Name

Company Address


Street

Apt# / PO Box

City

State	Postal Code

Company Phone Number

ext.

Position Held

Reason for Leaving

Personal References

List three persons for references, other than family members who have knowledge of your safety habits

Reference 1

First Name

Last Name

Phone Number

ext.

Reference 2

First Name

Last Name

Phone Number

ext.

Reference 3

First Name

Last Name

Phone Number

ext.

To be Read and Signed by Applicant

I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquires of my personal, employment, educational, financial, or medical history and other related matters as may be necessary for an employment decision. I herby release employers, schools, or persons from all liability in responding to inquiries in connection with my application. In the event I am employed, I understand that false or misleading information given in my application interview may result in discharge.

Applicant Name *

First Name

Last Name

Date *

Applicant Signature *

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