Job Application

Applicant's Information

Full Name*




Are you at least 18 years of age

Birth Date if UNDER 18

How did you find out about this job?

Do you have any relatives working here? (list names & relationship)

What job are you applying for?

Have you worked for us before?

Have you ever been convicted of a crime?
If YES, please explain:

Do you have any PENDING criminal charges?
If YES, please explain:

Do you have a valid New York State Driver's License?  YES NO

• Do you have ANY convictions related to moving violations within the last 3 years? (i.e. speeding, cell phone use, failing to yield, etc.)  YES NO

• Have you ever had your license suspended/revoked?  YES NO

• Have you ever been convicted of DWI or any incident involving harm to persons/property while driving?  YES NO
If YES to any of these questions, please explain:

What hours of the day are you able to work?

Number of hours per week you are able to work:

Days of availability:  M T W TH F S S



Graduate?  YES NO


Graduate?  YES NO


Graduate?  YES NO






employment History

List your last 4 employers, list most recent first. **Do NOT leave any gaps of 2 months or more. Provide an explination for any lapse in employment history.**


Employment 1:

Employment 2:

Employment 3:

Employment 4:

Personal References

Applicant's Agreement

I hereby represent that each answer to a question herein and on any attachments to the application and all other information otherwise furnished is true and correct. I further represent that such answers and information constitute a full and complete disclosure of my knowledge with respect to the question or subject to which the answer or information relates. I understand that any incorrect, incomplete or false statements or information furnished by me during the selection process will subject me to disqualification from consideration or discharge at any time. I hereby authorize my former employers to give any information they may have concerning me. I understand that if hired, any offer of employment is subject to satisfactory criminal background & fingerprinting checks.

I understand that Empower is a drug free workplace and I will be required to submit to and pass a drug test prior to beginning employment.

I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I further release Empower, and/or its representatives, from any and all liability which may be incurred as a result of collecting such information.

I understand this Application for Employment does not constitute an expressed or implied contract of employment and, if hired, I have the right to terminate my employment for any reason at any time.