Application for Employment

*Date of Application   

PERSONAL INFORMATION

*Last Name

*First Name

Middle Initial

Street Address

City

State

Zip Code

AL AK AZ AS CA CO CT DE DC FL GA HI ID IL IN IA KS LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY ND NC OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Home Phone

Cell or Other

*Social Security #

If under 18, do you have a work permit?

JOB INTERESTS

Position Desired

Date available to start work

Starting salary/wage expected per hour?

per week?

per month?

Are there any days of the week when you would not be available to work? Please specify.

How did you learn about this job opening?

EDUCATION AND TRAINING

Please Enter Highest Grade Completed and Name of School

What extracurricular activities did you participate in, or special skills did you acquire, at the above school(s) which might
be helpful for the job in which you are applying?

WORK EXPERIENCE

Begin with your present or more recent employer, describe your employment experience below:

Are you presently employed?

Are you on"layoff" and subject to recall?

If so, to where?

Yes No

Yes No

1. Present or Last Employer

Employer's Phone

Address

Kind of Business

Starting Position

Starting Pay

Final Position

Final Pay

Dates Employed
(From mm/yy - To mm/yy)

-

Description of your work & responsibilities

Reason for leaving

Will you receive a satisfactory reference
from this employer?

If No, Please Explain

Yes No

May we contact your present employer
at this time?

No, Explain

Yes No

2. Next Previous Employer

Employer's Phone

Address

Kind of Business

Starting Position

Starting Pay

Final Position

Final Pay

Dates Employed
(From mm/yy - To mm/yy)

-

Description of your work & responsibilities

Reason for leaving

Will you receive a satisfactory reference
from this employer?

If No, Please Explain

Yes No

May we contact your present employer
at this time?

Explain

Yes No

3. Next Previous Employer

Employer's Phone

Address

Kind of Business

Starting Position

Starting Pay

Final Position

Final Pay

Dates Employed
(From mm/yy - To mm/yy)

-

Description of your work & responsibilities

Reason for leaving

Will you receive a satisfactory reference
from this employer?

If No, Please Explain

Yes No

May we contact your present employer
at this time?

Explain

Yes No

4. Next Previous Employer

Employer's Phone

5. Next Previous Employer

Employer's Phone

PERSONAL INFORMATION

A record of criminal conviction will not necessarily be a bar to employment, since the Company will consider factors
such as age, time of the offense, the nature and seriousness of the violation, and the evidence of rehabilitation in
making any employment decision.

Have you ever been convicted of a crime, other than minor traffic violations?

If Yes, please give details

Yes No

Do you have a valid driver's license?

License Number

State

Yes No

Have you had any accidents in the last five years?

If yes, please give details.

Yes No

Have you been cited for any moving violations in the last five years?

If yes, please give details.

Yes No

Has your license been suspended, revoked, denied or cancelled?

If yes, please give details.

Yes No

PLEASE READ THE FOLLOWING PARAGRAPHS CAREFULLY

By signing below, I certify that I have read, understand, and agree to each of the following statements:

All of the information I have supplied on this application is true, accurate and complete, to the best of my knowledge, and I have not knowingly withheld any information which, if known to the Company, would affect my application unfavorably.

If I am hired by the Company, and if the Company discovers at any time during my employment that any of the statements or answers on this application are false, misleading, or incomplete, I may be dismissed immediately from my job,

I agree to submit to a medical examination, which may include testing for drugs or alcohol, prior to beginning work with the Company. I understand that if I am employed by the Company I may be required, when job-related and consistent with the Company's business needs, to undergo a medical examination or testing for alcohol. I further understand that I may be required to submit to a test for the use of illegal drugs at any time.

In consideration of my employment with the Company, I agree to abide by all the Company's rules and regulations.

I understand that nothing in this employment application creates a contract of employment between me and the Company. If I am hired by the Company, my employment and compensation are "at will," which means that my employment can be terminated, either by the Company or me, with or without cause, and with or without notice. I understand that no manager or supervisor has the authority to make any employment agreement with me, either orally or in writing, that is not an at will agreement. Only the President of the Company has the authority to enter into an employment agreement with me for any specified period of time.

I agree to release to the Company or its designated agents all medical information, including but not limited to files, reports, x-rays, evaluations, and opinions held by medical personnel, to the extent such information is job-related and consistent with the Company's business needs. I acknowledge that this is a general release and that if hired it remains in effect for the duration of my employment.

In the event of my personal indebtedness to the Company, I authorize the Company to withhold from my wages such amounts as permitted by law to satisfy my obligation to the Company.

I give the Company my permission to conduct any investigation regarding the information contained in my employment application, which the Company thinks is necessary to determine my qualification for assuming a job with the Company. I give the Company my permission to contact any former employer, school, college, or university, utility company, credit or finance bureau or office, any personal or professional reference, or any other appropriate source or individual for the purpose of gathering any information, personal or otherwise, that such sources may have about my character, general reputation, credit, education or employment record, and I give my consent to any such source to release to the Company whatever information they have about me. I also unconditionally release all named and unnamed sources from any and all liability which might result from furnishing any information about me.

*Signature

*Confirm Signature

*Email Address

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