Employment Application

An Equal Opportunity Employer

Date

Last Name

First Name

Middle

Street Address

City

State

Zip Code

Permanent Address (if different from present address)

City

State

Zip Code

Business Phone

Home Phone

Email Address

Employment Desired

Position Applying for:

Message / Comments

Personal Information

How did you hear about our company and this job opening?

Have you ever applied to or worked for us before?

If yes, when?

Why are you applying for work at The Natoma Company?

If hired, would you have a reliable means of transportation to and from work?

Are you at least 18 years old?

(If under 18, hire is subject to verification that you are of minimum legal age.)

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?

If no, describe the functions that cannot be performed.

(Note: We comply with the ADA and consider reasonable accommodation 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.)

We may refuse to hire relatives of present employees if doing so could result in actual or potential problems in supervision, security, safety, or morale, or if doing so could create conflicts of interest.

Education, Training, and Experience

High School

Name

Address

City

No. of Years Completed

State

Did you graduate?

Zip

Degree or Diploma

College/University

Name

Address

City

No. of Years Completed

State

Did you graduate?

Zip

Degree or Diploma

Vocational/Business

Name

Address

City

No. of Years Completed

State

Did you graduate?

Zip

Degree or Diploma

Health Care Training

Name

Address

City

No. of Years Completed

State

Did you graduate?

Zip

Degree or Diploma

Employment History

List below all present and past employment starting with your most recent employer (last five years is sufficient). You mus complete this section even if attaching a resume.

Name of Employer

Type of Business

Phone Number

Supervisor's Name

Address

City

State

Zip

Dates of Employment:

From:

To:

Current Employer?

Yes

May we contact this employer for a reference?

Yes

Your Position and Duties

Reason for Leaving

Name of Employer

Type of Business

Phone Number

Supervisor's Name

Address

City

State

Zip

Dates of Employment:

From:

To:

Current Employer?

Yes

May we contact this employer for a reference?

Yes

Your Position and Duties

Reason for Leaving

References

List below three persons not related to you who have knowledge of your work performance within the last three years.

First Name

Last Name

Phone Number

Address & Street

City

State

Zip Code

Occupation

No. of Years Acquainted

First Name

Last Name

Phone Number

Address & Street

City

State

Zip Code

Occupation

No. of Years Acquainted

First Name

Last Name

Phone Number

Address & Street

City

State

Zip Code

Occupation

No. of Years Acquainted

Please Read Carefully and Check the Box Next to Each Paragraph Confirming You Agree to the Terms.

Confirm

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.

Confirm

I hereby authorize The Natoma Company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I 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, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

Confirm

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.

Confirm

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

The Company will consider qualified applicants, including those with criminal histories, in a manner consistent with state and local "Fair Chance" laws.

Today's Date

Type Name for Authorization