Date: _________________

APPLICATION FOR EMPLOYMENT

Instructions (please print all information)
This Application must be completed accurately and in full even if attaching a resume.  Before signing this Application, please carefully read the entire application including, in particular, the Applicant Acknowledgment and Authorization appearing toward the end of this application.

Personal

Name: ______________________________________  	SS #:____________________
	 Last 		First	         Middle

Address: ___________________________________________________________________
		Street			City 			State 		Zip Code

Home#: ___________________ Cell#:__________________ Work#:_______________

Date of Birth:  ___________________________

Are you legally eligible for employment in the United States of America? 
Yes __ No __ (If “Yes”, verification will be required.)

Are you at least 18 years of age? Yes ___ No ___
If  “No”, do you have a work permit? Yes ___ No ___

Position applying for: _____________________ 
Salary/ hourly rate desired: $______________
Hours and days that you are available to work:_______________________________________________________________
If hired, when would you be available to begin work?   _______________________________________________________________

Have you ever been convicted of, or plead guilty to, a felony crime? 
Yes ___ No___
If “Yes”, provide the date(s) of your conviction(s) or guilty plea(s), a description of the crime(s) and the sentence received: _______________________________________________________________________

_______________________________________________________________________

Previous Employment 
(Begin With Most Recent Position)

1. Name of employer:____________________________________________
    Address:____________________________________________________
    Telephone #:________________________________________________
    Name of your supervisor/manager:____________________________
    Position held:___________________________ 
    Salary/ hourly pay rate:_________________
    Describe the work you did:________________________________
    Dates employed: ____________ - ____________
				(mo./yr.)	    (mo./yr.)
    Reason for leaving: 
		Resignation ____ or Involuntary Discharge ____
In either case, explain: ________________________________________________________________
    ________________________________________________________________

2. Name of employer:____________________________________________
    Address:____________________________________________________
    Telephone #:________________________________________________
    Name of your supervisor/manager:____________________________
    Position held:___________________________ 
    Salary/ hourly pay rate:_________________
    Describe the work you did:________________________________
    Dates employed: ____________ - ____________
				(mo./yr.)	    (mo./yr.)
    Reason for leaving: 
		Resignation ____ or Involuntary Discharge ____
In either case, explain: ________________________________________________________________
    ________________________________________________________________

3. Name of employer:____________________________________________
    Address:____________________________________________________
    Telephone #:________________________________________________
    Name of your supervisor/manager:____________________________
    Position held:___________________________ 
    Salary/ hourly pay rate:_________________
    Describe the work you did:________________________________
    Dates employed: ____________ - ____________
				(mo./yr.)	    (mo./yr.)
    Reason for leaving: 
		Resignation ____ or Involuntary Discharge ____
In either case, explain: ________________________________________________________________
    ________________________________________________________________

4. Name of employer:____________________________________________
    Address:____________________________________________________
    Telephone #:________________________________________________
    Name of your supervisor/manager:____________________________
    Position held:___________________________ 
    Salary/ hourly pay rate:_________________
    Describe the work you did:________________________________
    Dates employed: ____________ - ____________
				(mo./yr.)	    (mo./yr.)
    Reason for leaving: 
		Resignation ____ or Involuntary Discharge ____
In either case, explain: ________________________________________________________________
    ________________________________________________________________

With the exception of any employer listed immediately below, I authorize you to contact the employers and supervisors/managers listed above concerning my work experience.

Signed: ___________________________________Date:________________

List any previous employer that you do not want us to contact and state why: ______________________________________________________________________ 

______________________________________________________________________

Education

High School 
	Name: _____________________________________
	Address: _________________________________________________
	Did you graduate? Yes ____ No ____
	Honors received: __________________________________________

College
	Name: _____________________________________
	Address: __________________________________________________
	Did you receive a degree? Yes ____ No _____
	If “Yes”, type of degree received: ______________________________
	Major: ____________________; Minor: _________________________
	Honors received: ___________________________________________

Graduate Studies
	Name: _______________________________
	Address: __________________________________________________
	Did you receive a degree? Yes ____ No _____
	If “Yes “, type of degree received: ______________________________
	Honors received: ____________________________________________

Other (e.g., professional certificates, training, education, etc.)
	Name: _________________________________
	Address: ___________________________________________
	Certificate, training or additional education received: _______________________________________________________________

Applicant Acknowledgment and Authorization

The information provided by me on this Application for Employment is true, accurate and complete.  I understand that any misrepresentations, false statements, false information, or material omissions on this Application for Employment (or on any other accompanying or required documents) may result in the exclusion of my Application for Employment from further consideration or, if I am hired, termination of my employment regardless of when or how discovered.  I further understand that neither this Application for Employment nor any other document or statement of the Company constitute a contract or agreement of employment.  I understand that if I am hired my employment will be “at-will” and, as such, may be terminated by either party at any time, with or without cause and with or without notice.  If hired, I agree to comply with all policies, rules and regulations of the Company.

I authorize the Inn at Millrace Pond, to contact the employers, supervisors, managers and educational institutions identified above for purposes of verifying the accuracy of the information contained in this Application for Employment.

Signature of Applicant:________________________________________

Dated:_________________________________________________________

The Inn at Millrace Pond is an equal employment opportunity employer.  We do not discriminate in employment opportunities, policies or practices on the basis of race, color, creed, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, citizenship, age, veteran status, disability or any other characteristics protected by law.  The Inn at Millrace Pond will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship as defined by law.