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A.G. Dillard - Online Application for Employment

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

* (indicates required field)

Position(s) Applied for*:
 Date of Application*:
How did you learn about us?
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Employment Agency 		Relative
Friend 		Inquiry
Other:    

Last Name*:
 First Name*:
 Middle Name:
Address*:
 Apt #:
 City*:
 State*:
 Zip Code*:
Telephone (home)*:
 Telephone (cell):
 Best time to contact you at home is:

If you are under 18 years of age, can you provide proof of your eligibility to work?*
Have you ever filed an application with use before?*
     If yes, give date:
Have you ever been employed with us before?*
     If yes, give date:
Do any of your friends or relatives, other than spouse, work here?*
Are you currently employed?*
May we contact your present employer?*
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?* (proof of citizenship status will be required upon employment)
Date available for work:* What is your desired salary range?
Are you currently on "lay-off" status and subject to recall?*
Can you travel if a job requires it?*

Employment Experience
Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

1.
Employer Job Title
Address / City / State / Zip
Telephone Number Supervisor
Reason for Leaving
Dates Employed
From To
Hourly Rate/Salary
Starting Final
Description of Work Performed
2.
Employer Job Title
Address / City / State / Zip
Telephone Number Supervisor
Reason for Leaving
Dates Employed
From To
Hourly Rate/Salary
Starting Final
Description of Work Performed
3.
Employer Job Title
Address / City / State / Zip
Telephone Number Supervisor
Reason for Leaving
Dates Employed
From To
Hourly Rate/Salary
Starting Final
Description of Work Performed
4.
Employer Job Title
Address / City / State / Zip
Telephone Number Supervisor
Reason for Leaving
Dates Employed
From To
Hourly Rate/Salary
Starting Final
Description of Work Performed

References

Name:
 Relationship:
Address:
 Telephone:
Name:
 Relationship:
Address:
 Telephone:
Name:
 Relationship:
Address:
 Telephone:

Additional Comments/Questions


Applicants Statement

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.




Signature of Applicant* (type name)
Date*