Nickerson & O'Day, Inc.

Employment Application

Application Information

First Name(*)
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Middle Initial
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Last Name(*)
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Date(*)
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Street Address(*)
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Apartment/Unit #
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City
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State
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Zip Code
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Phone
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E-mail Address
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Date Available
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Wage Desired
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Position Applied For
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Are you a citizen of the United States?
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If no, are you authorized to work in the U.S.?
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Have you ever worked for this company?(*)
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If so, when?
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Have you ever been convicted of a felony?(*)
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If yes, explain
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Education

High School
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Address
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From
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To
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Did you graduate?
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Degree
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College
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Address
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From
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To
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Did you graduate?
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Degree
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Other Special Skill or Training
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References

Please list three references:

Full Name
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Relationship
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Company
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Phone
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Full Name
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Relationship
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Company
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Phone
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Full Name
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Relationship
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Company
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Phone
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Previous Employment

Company
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Phone
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Address
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Supervisor
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Job Title
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Starting Wage
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Ending Wage
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Responsibilities
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From
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To
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Reason for Leaving
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May we contact your previous supervisor for a reference?
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Company
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Phone
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Address
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Supervisor
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Job Title
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Starting Wage
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Ending Wage
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Responsibilities
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From
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To
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Reason for Leaving
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May we contact your previous supervisor for a reference?
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Company
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Phone
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Address
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Supervisor
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Job Title
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Starting Wage
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Ending Wage
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Responsibilities
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From
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To
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Reason for Leaving
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May we contact your previous supervisor for a reference?
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Military Service

Branch
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From
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To
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Rank at Discharge
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Type of Discharge
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If other than honorable, explain
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Accommodations

Do you have any physical or mental handicap which would prevent you from performing the job you are applying for?
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Accommodations required, if any
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Disclaimer and Signature

I certify all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.

Signature(*)
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Date(*)
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