Support Services of America, Inc. We appreciate your interest in our organization and are sincerely interested in your
qualifications. A clear understanding of your background and work history will help
us potentially place you in a position that meets your objectives and those of the
organization.
Application for Employment We consider applicants for all positions without regard to race, color, religion, sex,
national origin, age, marital or veteran status, sexual orientation, the presence of a
non-job related medical condition or handicap, or any other legally protected
status.

Position(s) Applied For:
Date of Application: *MM/DD/YYYY

First Name:
Last Name:
Middle Name:
Address:

Apt #:

City:
State:

Zip:

Phone Number:
Area Code    Number
Social Security #:

If you are under 18, can you funish a work permit? Y    N
Have you ever been employed here before? Y    N
Are you legally eligible for employment this country?
(proof of U.S. citizenship or immigration status will be required upon emplyment)
Y    N
Date available for work *MM/DD/YYYY

Please indicate the hours that you are available to work on each day of the week

Hours: Sun. Mon. Tue. Wed. Thur. Fri. Sat.
From:
To:

Have you ever been convicted of a felony in the last seven (7) years?
(Such conviction may be relevant if job-related, but does not bar your employment)
Y    N
If yes, please explain

Salary Desired: $

Employment History - List your last three (3) employers, beginning with the most recent
From *MM/DD/YYYY

To *MM/DD/YYYY

Employer:
Phone:
Job Title:

Address:
Immediate Supervisor and Title:
May we contact your present employer?
Y    N          If Not, why?
Reason for Leaving:
Hourly Rate / Salary:
Start $    Per    Final $    Per

From *MM/DD/YYYY

To *MM/DD/YYYY

Employer:
Phone:
Job Title:

Address:
Immediate Supervisor and Title:
Summarize the nature of work preformed and job responsibilities
Reason for Leaving:
Hourly Rate / Salary:
Start $    Per    Final $    Per

From *MM/DD/YYYY

To *MM/DD/YYYY

Employer:
Phone:
Job Title:

Address:
Immediate Supervisor and Title:
Summarize the nature of work preformed and job responsibilities
Reason for Leaving:
Hourly Rate / Salary:
Start $    Per    Final $    Per


Education
School or Institution Name and Location of School Major Units completed and grade average Graduated Yes / No Year
High School Y    N  
College Y    N  
Graduate Y    N  
Other Y    N  
Honors or Awards Received Y    N  

Have you ever been discharged or forced to resign from any position? Y    N  
If yes, please explain in detail

Do you have any relatives employed by us? Y    N
If yes:

Name(s)
Relationship(s)
Location(s)

References
List people we may contact who are qualified to evaluate your capabilities. (Do not include relatives)
Name Telephone Relationship Years Known


ACKNOWLEDGMENT

  1. Any acceptance of employment will be predicated upon the truthfulness of the written and verbal statements contained within this application and pre-employment process. I understand that should my employer find that any statement I have made is not truthful, any job offer extended to me will be withdrawn and if employed, I may be subject to dismissal.
  2. I authorize my employer to make any investigation deemed necessary for employment consideration and promotion within the organization which may include, but not limited to, securing additional information (such as a Criminal background check). I understand that a bonding and a security investigation may be made whereby information is obtained through personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors, or others with whom I am acquainted. I hereby release all persons from any liability in this investigation.
  3. I understand this employment application is not to be construed as a guarantee of employment for a specific time. I further understand that my employment with the organization does not constitute any form of contract, implied or expressed, and such employment will be terminable at-will either by myself or my employer upon notice of one party to the other. My continued employment is dependent on satisfactory performance and the continued need for my services as determined by the organization.
  4. I grant my employer approval, after my termination of employment, to release information that it may deem appropriate regarding my employment with or termination from the organization, to anyone who has a reasonable basis for making such inquiry. So long as the information disclosed is not known by the organization to be inaccurate, the organization shall not incur legal liability of any nature in connection with the furnishing of such information.
  5. I acknowledge that I have read all of the above statements and that I understand them.

I understand it is the Company’s policy not to refuse to hire a qualified individual with a disability because of this person’s need for an accommodation that would be required by the Americans with Disabilities Act (ADA).

I agree to the above acknowledgment