Employment Application All * Questions MUST Be Answered First Name Middle Last Name Please enter any other name(s) you have used in the field below: Address City State Zip How long have you lived there? years years months months Primary Phone Other Phone Email Address Position Applied for If you are 18 years of age, and if you are hired, can you provide required proof of your eligibility to work? Yes No If hired, can you provide proof that you are authorized to work in the U.S. on an unrestricted basis? Yes No Have you ever filed an application with us before? Yes No If yes, give date If yes, give date Have you ever been employed with us before? Yes No If yes, give dates If yes, give dates Are you currently employed? Yes No Are you currently on “lay-off” status and subject to recall? Yes No May we contact your present employer? Yes No If no, explain why not: If no, explain why not: If yes, please fill in below: Company Name Contact Name Telephone Email On what date would you be available for work? When are you available to work? (Check all that apply) Full time Part time Shift work Temporary Can you travel if a job requires it? Yes No Are you capable of satisfactorily performing the essential job duties of the position, with or without reasonable accommodation, for which you are applying? Yes No Do you have adequate transportation to and from work? Yes No Have you ever pled guilty or “no contest” to, or been convicted of a serious misdemeanor or felony? Yes No If yes, explain: If yes, explain: Submit We are an equal opportunity employer. We consider applications for all positions without regard to race, color, religion, gender, national origin, sexual orientation, age, martial status, pregnancy, veteran status, disability, or any other legally protected status. 061019 22 Greeley Street, Suite 6 | Merrimack, NH 03054 | 603.261.3128
