Employee Application Form

(Print this form, fill it out and mail it to us at the address listed below)

ALL PERSONS SHALL HAVE THE OPPORTUNITY TO BE CONSIDERED FOR EMPLOYMENT WITHOUT REGARD TO THEIR RACE, COLOR, RELIGION, NATIONAL ORIGIN OR ANCESTRY, AGE, PAST OR PRESENT DISABILITY, SEX, OR ANY OTHER CHARACTERISTIC PROTECTED BY THE APPLICABLE STATE AND FEDERAL LAWS.

DATE:________________

PERSONAL INFORMATION

NAME:_______________________________________________________________________________________

ADDRESS:___________________________________________________________________________________

TELEPHONE:__________________________________ SOCIAL SECURITY NO.:_____________________

POSITION FOR WHICH YOU ARE APPLYING

_____________________________________________________________________________________________

YOUR AVAILABILITY (CHECK ONE)

FULL TIME: ______ PART TIME: ______ SALARY REQUEST: __________________

THE DAYS YOU ARE AVAILABLE TO WORK:

MON____ TUE____ WED____ THURS____ FRI____ SAT____ SUN____

REFERENCES

NAME AND OCCUPATION ADDRESS PHONE

_______________________________ _____________________ ___________________

FORMER EMPLOYERS

LIST BELOW YOUR WORK EXPERIENCE, STARTING WITH YOUR PRESENT OR LAST PLACE OF EMPLOYMENT.

	DATE EMPLOYED	NAME & ADDRESS OF EMPLOYER	NAME OF SUPERVISOR	POSITION, SALARY AND REASON FOR LEAVING
FROM:
TO:


FROM:
TO:

FROM:
TO:

FROM:
TO:

EDUCATION

HIGHEST GRADE COMPLETED 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4
GRADE SCH. HIGH SCH. COLLEGE

NAME OF LAST SCHOOL ATTENDED___________________________________________________

VOCATIONAL OR TRADE SCHOOL_____________________________________________________

COURSE OF STUDY___________________________________________________________________

STATE ANY OTHER JOB RELATED EDUCATION, TRAINING OR EXPERIENCE THAT YOU MAY HAVE RECEIVED THROUGH VOLUNTEER OR OTHER ACTIVITIE:

_________________________________________________________________________________________

STATEMENT

I HAVE READ AND FULLY UNDERSTAND THE QUESTIONS ASKED IN THIS APPLICATION. I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE AND UNDERSTAND THAT THE OMISSION AND/OR MISREPRESENTATION OF ANY FACT FROM THIS APPLICATION OR DURING ANY INTERVIEW WILL BE CAUSE FOR IMMEDIATE DISMISSAL. I HEREBY AUTHORIZE THE COMPANY TO OBTAIN REFERENCE INFORMATION ABOUT ME AND RELEASE ALL PERSONS FROM LIABILITY FOR DOING SO.

IF HIRED, I AGREE TO ABIDE BY ALL OF THE COMPANY RULES AND REGULATIONS AND UNDERSTAND THAT, IF EMPLOYED; MY EMPLOYMENT MAY BE TERMINATED WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT THE OPTION OF EITHER THE COMPANY OR ME. I FURTHER UNDERSTAND THAT NO REPRESENTATION, WHETHER ORAL OR WRITTEN, BY ANY REPRESENTATIVE OR AGENT OF THE COMPANY, AT ANY TIME. CAN CONSTITUTE A CONTRACT OF EMPLOYMENT. I UNDERSTAND THAT THE COMPANY AND ALL PLAN ADMINISTRATORS SHALL HAVE THE MAXIMUM DISCRETION PERMITTED BY LAW TO ADMINISTER, INTERPRET, MODIFY, DISCONTINUE, ENHANCE, OR OTHERWISE CHANGE ALL POLICIES, PROCEDURES, BENEFITS OR OTHER TERMS OR CONDITIONS OF EMPLOYMENT. NO REPRESENTATIVE OR AGENT OF THE COMPANY HAS THE AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME OR TO MAKE ANY CHANGE IN ANY POLICY, PROCEDURE, BENEFIT OR OTHER TERM OR CONDITION OF EMPLOYMENT OTHER THAN IN A DOCUMENT SIGNED BY MICHAEL MOSCATIELLO, PRESIDENT, AND ME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.

DATE______________ SIGNATURE OF APPLICANT________________________________________

Mail application to:
Moscatiello's
99 North Greenbush Road
Troy, New York 12180