BWapplication

Application for Employment
BW Location:_________________________ Today’s Date: ___________________
Name: (Last)____________________________________ (MI)________ (First)____________________
Address: ________________________________________________________________
City: ________________________________ State: _______ Zip Code: ______________
Phone: (Hm)________________________________ (Wk) ________________________________
Are you over 18 years of age? Yes_____ No_____
Position: ______________________ Full-time_____ Part-time_____ Temporary (Seasonal)_____
Wage Desired: ________________Date Available: ___________
Emergency Contact Information -

Name:________________________________________________________
Address: ______________________________________________________
City: _____________________________ State:______ Zip Code:_________
Phone: (Home)__________________________ (Work) ___________________________
Will you be able to submit verification of your legal right to work in the United States, if
employed? Yes_____ No_____
Have you ever been convicted of a felony? Yes_____ No_____
If yes, please explain:______________________________________________________
(NOTE: conviction will not necessarily disqualify you as an eligible applicant)
Are you willing to relocate? Yes_____ No_____

Driver’s License # (if position requires driving): __________________
Are you willing to work any days or shifts, including overtime, as necessary? Yes___ No___
Preferred days or shifts: ____________________________________________________
1
Have you ever been, or are you currently employed by any Burke Williams?
Yes___ No___ If yes, at which location were you employed: _________________
Dates of employment: ___________________ Position held: _________________
Are you able to perform the essential functions of the position for which you are
applying, either with or without reasonable accommodations? Yes_____ No_____
If necessary, please describe reasonable accommodations necessary:
________________________________________________________________________
________________________________________________________________________
Education -
School Attended Name/ Address/ Phone Graduated Course/ Major
High School Yes___ No___
College/ University Yes___ No___
Massage/ Technical/ Yes___ No___

Vocational
Certifications, CPR Training, Licenses (include city, state & national):

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Seminars, workshops, special training, professional associations/ technical affiliations (as it

relates to the position for which you are applying):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2
Employment –
List all jobs, military service and/or self-employment beginning with present:
May we
Company Name, Dates of Rate of Position Reason for contact?
Address & Phone # Employment Pay Termination (yes or no)
From: $
To: $
From: $
To: $
From: $
To: $
From: $
To: $
Professional References –
List below three persons not related or residing with you who are willing to provide a
professional reference:
1. Name _________________________________Phone:________________
Number of Years Acquainted ________________
2. Name _________________________________Phone:________________
3. Name _________________________________Phone:________________
3
I hereby certify that the information contained in this application form is true and
correct to the best of my knowledge and agree to have any of the statements checked by the
company unless I have indicated to the contrary. I authorize the references listed above to
provide the company any and all information concerning my previous employment and
any other pertinent information that they may have. Further, I release all parties and
persons from any and all liability for any damages that may result from furnishing such
information to the company as well as from the use or disclosure of such information by
the company or any of its agents, employees, or representatives. I understand that any
misrepresentation, falsification, or material omission of information on this application
may result in my failure to receive an offer or, if I am hired, my dismissal from
employment.
In consideration of my employment, I agree to conform to the rules and standards

of the company and agree that my employment and compensation can be terminated at
will, with or without cause, and with or without notice, at any time, either at my option or
at the option of the company. I understand that no employee or representative of the
company, other than its president, has the authority to enter into any agreement for
employment for any specified period of time, or to make any express or implied agreement
contrary to the foregoing. Further, the president of the company may not alter the at-will
nature of the employment relationship or enter into any employment agreement for a
specified time unless the president and I both sign a written agreement that clearly and
expressly specifies the intent to do so. I agree that this shall constitute a final and fully
binding integrated agreement with respect to the at-will nature of my employment
relationship and that there are no oral or collateral agreements regarding this issue.
I also understand that all offers of employment are conditioned on the provision of
satisfactory proof of an applicant’s identity and legal authority to work in the U.S. Offers
of employment are also conditioned on the company’s receipt of satisfactory responses to
reference requests and the satisfactory completion of a post-offer medical examination.
________________________________________________ __________________
Applicant’s Signature Date
Burke Williams wishes to reaffirm its goal of promoting equal opportunities in the work
place. Burke Williams is an equal opportunity organization and does not discriminate
based on an applicant’s or employee’s race, color, religion, sex, pregnancy, sexual
orientation, national origin, ancestry, citizenship, age, physical or mental disability, or any
other characteristic protected by state or federal law.
4
Equal Opportunity Employer

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Application for Employment

BW Location:_______ Today’s Date: _

Name: (Last)________________ (MI) (First)

City: ____________________________ State: _ Zip Code: ____________

Phone: (Hm) (Wk)

Are you over 18 years of age? Yes_ No_

Position: ____________________ Full-time_ Part-time_ Temporary (Seasonal)___

Wage Desired: ______Date Available: _

Emergency Contact Information -

Are you willing to relocate? Yes_ No_

Dates of employment: ___ Position held: _

School Attended Name/ Address/ Phone Graduated Course/ Major

High School Yes_ No_

College/ University Yes_ No_

Massage/ Technical/ Yes_ No_

Certifications, CPR Training, Licenses (include city, state & national):

Seminars, workshops, special training, professional associations/ technical affiliations (as it

In consideration of my employment, I agree to conform to the rules and standards

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