Employment Application

Employment Application

Application for Employment
Step 2: Application Form

We are an equal opportunity employer and do not unlawfully discriminate in employment. No question in this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization.

Please fill out the form below. Fields marked with * are required.
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General Information:

Full name:*

Position applied for or type of work desired:*

Full address:*

Phone:*

(include area code)

Alternate Phone:

(include area code)

Email address:*

Type of employment desired:*

Full-time Part-time
Co-op/Internship Temporary

Date available to start work:*

What is your highest educational degree attained and in what discipline?

Can you travel if required by this position?*

Yes No

Have you ever been previously employed by our organization?*

Yes No

Our work involves Government contracts and our employees have to be U.S. citizens. Can you present proof of U.S. citizenship?*

Yes No

Can you submit proof of legal employment authorization and identity? (a social security card or passport will be required for in-processing)*

Yes No

If you are under 18, can you furnish a work permit if it is required? (check n/a if you are 18 or older)

Yes No n/a

Have you been convicted of a crime in the last seven (7) years?*

Yes No

If yes, you must explain (a conviction may not necessarily bar employment):

Have you ever been employed by the US Government?*

Yes No

If yes, please explain any post-Government employment restrictions:

How did you find out about this position, or how were you referred to us?*

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Employment History

Current/Last Position

Employer:
Address:
Job title:
Supervisor's name:
May we contact your supervisor?	Yes No
Supervisor's Phone: Email:
Time at this position:	From: To: (mm-dd-yyyy)
Responsibilities:
Salary:	per (hour, month, or year)
Reason for leaving:

Previous Position

Employer:
Address:
Job title:
Supervisor's name:
May we contact the supervisor?	Yes No
Supervisor's Phone: Email:
Time at this position:	From: To: (mm-dd-yyyy)
Responsibilities:
Salary:	per (hour, month, or year)
Reason for leaving:

Previous Position

Employer:
Address:
Job title:
Supervisor's name:
May we contact the supervisor?	Yes No
Supervisor's Phone: Email:
Time at this position:	From: To: (mm-dd-yyyy)
Responsibilities:
Salary:	per (hour, month, or year)
Reason for leaving:

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Personal and/or Professional References (you must list at least 3, and they should be someone other than a supervisor listed above):

Name (1):
Telephone Number:

Name (2):
Telephone Number:

Name (3):
Telephone Number:

Name (4):
Telephone Number:

Please supply any other information that might be helpful to your application:

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Understandings and Signature

Note: Checking the boxes below constitutes the equivalent of signing the employment application form and understanding the ramifications and conditions of employment.
*	I hereby authorize Cornerstone Research Group (CRG), or its sister company CRG Industries, to contact, obtain, and verify the accuracy of information contained in this application and in my résumé from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.
*	I certify that all information contained in this application is true and complete. I further understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment at the potential employer if I am employed, whenever a misrepresentation or material omission may be discovered.
*	If employed by the potential employer, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, once employed, either I or the potential employer can terminate the employment relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.
*	I understand that it is the policy of the potential employer not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of a need for a reasonable accommodation as required by the ADA.
*	I understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired.
*	I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.
To validate the form, type the letters and numbers as you see them in this graphic (case-sensitive):