Campbell Real Estate Employment Application
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
Personal
Last Name			First Name		Initial	Social Security No.			Date
Permanent Address						City/State/Zip			Telephone:
Are you over 18 yrs of age?			Can you prove eligibility to work in USA?			Other names under which you have previously been employed
Yes	No	(Circle One)	Yes	No	(Circle One)
Name of friend or relatives employed in this Organization
Have you ever applied to this organization before?				If yes, give date and position applied for
Yes	No	(Circle One)
Have you ever been employed by us before?				If yes, give dates of employment			Are you free to work overtime/weekends, or be on call?
Yes	No	(Circle One)					Yes	No	(Circle One)
Have you ever been convicted of a felony?				If yes, give location, date, and description
Yes	No	(Circle One)
Driving jobs only, has your driver's license been revoked or suspended in the last 3 years?							Date, state, and license number
Yes	No	(Circle One)
Have you ever been terminated or asked to resign?				If yes, briefly explain
Yes	No	(Circle One)
In case of emergency, notify:				ADDRESS					TELEPHONE
Relationship:				DOCTOR:					TELEPHONE
Employment Interests
Position desired or area of interest					Date available			Pay expected
Type of employment you are seeking				How were you referred to our organization?
Full time	Part time	(Circle One)
Education
Name and address of school or institution					Major	Units completed and grade average			Degrees and/or Diplomas
High School
College
Other
Are you taking any educational course presently?				If yes, what course and where?
Yes	No	(Circle One)
Please provide any other information that will assist us in evaluating your application, including technical training, community affiliations, memberships and scholastic awards. You may exclude affiliations that indicate race, color, ancestry, gender, religion, age, national origin, or other protected classification.
References
List people we may contact who are qualified to evaluate your capabilities. Do not include relatives.
Name		Address		City/State/Zip		Telephone		Occupation		Yrs. Known
Employment History
Give employee record, listing current or most recent employer first. Show unemployed or self-employed periods and indicate dates and comment on each period. You may use extra sheets for additional information. A resume may be used to supplement (but not replace) this information.
Company Name (Current or last)				Telephone		Job Title		Dates Employed (Month/Year)
								From:	To:
Address				City/State/Zip		Type of Business		Base Rate of Pay (Hr./Wk./Mo.)
Supervisor's Name and Title				Reason for Leaving				May We Contact this Employer?
								Yes	No	(Circle One)
Description of Duties
Company Name (Current or last)				Telephone		Job Title		Dates Employed (Month/Year)
								From:	To:
Address				City/State/Zip		Type of Business		Base Rate of Pay (Hr./Wk./Mo.)
Supervisor's Name and Title				Reason for Leaving				May We Contact this Employer?
								Yes	No	(Circle One)
Description of Duties
Acknowledgement
1. I certify, under the penalty of perjury, that all of the above information is true and complete, and I understand that any misrepresentation, falsification or omission of information may result in the denial of employment or, if hired, may result in termination.
2. I authorize Campbell Real Estate to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment. I further authorize the listed employers, schools and personal references to give Campbell Real Estate (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have.
3. I expressly agree and understand that, if employed, my employment, having no specific term, is based upon mutual consent and my be terminated at will, with or without cause or notice, by either party (Campbell Real Estate or me).
4. I hereby acknowledge that I may be required to submit to a urinalysis and/or chemical screening and/or a physical examination/work skills assessment subsequent to an offer of employment. Refusal to submit to a urinalysis and/or chemical screening, a physical examination/work skills assessment, confirmation of a positive urinalysis and/or chemical screening test result, or unacceptable results of a physical examination/work skills assessment will result in withdrawal of any employment offer and may result in denial of any future consideration for employment.
Signature								Date