An Equal Opportunity Employer
We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, genetic information or any other status protected by law or regulation. It is our intention that all qualified applicants are given equal opportunity and that selection decisions be based on job-related factors.

Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information.

Today’s Date: 9/3/2010
Job Applied for:*

Are you seeking:

Full-time

Part-time

Temporary

Employment?

When could you start work:

Name (F,M,L):*
Address:*
City,State,Zip:*
Phone/ext:*
Email Address:*

Are you 18 years of age or older?	Yes:		No:
(If you are hired, you may be required to submit proof of age.)

If hired, can you furnish proof you are eligible to work in the U.S.?

Yes:

No:

Have you ever applied here before?
Yes:		No:		If yes when:

Were you ever employed here?
Yes:		No:		If yes when:

If employed, do you expect to be engaged in any additional business or employment outside of our job?
Yes:		No:		If yes, give details:

Have you ever been convicted of any law violation? Include any plea of “guilty” or “no contest.” (Exclude minor traffic violations.)
Yes:		No:		If yes, give details:
(A conviction will not necessarily disqualify an applicant for employment.)

For Driving Jobs Only: Do you have a valid driver’s license?

Yes:

No:

Driver’s License Number:
Class of License:
State Licensed In:

Have you had your driver’s license suspended or revoked in the last 3 years?
Yes:		No:		If yes, give details:

List professional, trade, business or civic activities and offices held.
(Exclude labor organizations and memberships which reveal race, color, religion, national origin, sex, age, disability, genetic information or other protected status.)

LIST NAME AND ADDRESS OF SCHOOLS	Number of Years Completed Diploma/ Degree/ Certificate Subjects Studied
High School or GED:
College or University:
Vocational or Technical:
What skills or additional training do you have that relate to the job for which you are applying?
What machines or equipment can you operate that relate to the job for which you are applying?

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. Note: A job offer may be contingent upon acceptable references from current and former employers.

NAME OF EMPLOYER JOB TITLE AND DUTIES ADDRESS CITY, STATE, ZIP CODE DATES OF EMPLOYMENT (MO/YR): PAY: START $ FINAL $ SUPERVISOR(S) TELEPHONE Reason For Leaving

NAME OF EMPLOYER JOB TITLE AND DUTIES ADDRESS CITY, STATE, ZIP CODE DATES OF EMPLOYMENT (MO/YR): PAY: START $ FINAL $ SUPERVISOR(S) TELEPHONE Reason For Leaving

NAME OF EMPLOYER JOB TITLE AND DUTIES ADDRESS CITY, STATE, ZIP CODE DATES OF EMPLOYMENT (MO/YR): PAY: START $ FINAL $ SUPERVISOR(S) TELEPHONE Reason For Leaving

NAME OF EMPLOYER JOB TITLE AND DUTIES ADDRESS CITY, STATE, ZIP CODE DATES OF EMPLOYMENT (MO/YR): PAY: START $ FINAL $ SUPERVISOR(S) TELEPHONE Reason For Leaving

Have you worked or attended school under any other names?
Yes:		No:		If yes, give names:

Are you presently employed?
Yes:		No:		If yes, whom do you suggest we contact?

Have you ever been fired from a job or asked to resign?
Yes:		No:		If yes, please explain:

Give three references, not relatives or former employers (Name, Address, Phone).

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZATION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE PRESIDENT AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.

Please enter your full name here as a form of an electronic signature:

*Required

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