Employment Application

PERSONAL INFORMATION

Name*
Position Applied For*
Phone Number*
Other Phone Numbers
Email Address*
Present Address(Street)*
City*
State*
Zip Code*
Date of Birth*
Age*
If under the age of 18, can you provide the necessary work certification at the time of employment? YesNoN/A
Type of employment desired? Full-TimePart-Time
If part time specify hours:
Are you willing to work overtime?* YesNo
Date on which you can start if hired*
Have you previously applied for employment with this company?* YesNo
If Yes, provide when and where you applied:
Have you ever been employed by this company?* YesNo
If Yes, provide dates of employment, location, and reason for separation from employment:
If applicable, below list any other names by which you have been known which may be necessary to allow us to confirm your work and educational records. for example; change of name, use of an assumed name, nickname.

EDUCATION

High School - Name and Location (Address, City, State)*
Course of Study
Number of Years Completed*
Graduate*
YesNo

  

If You did not graduate, do you have a GED?
YesNo
College - Name and Location (Address, City, State)
Course of Study
Number of Years Completed
Degree/Major*
Graduate*
YesNo
Honors Received
Secondary Education, College - Name and Location (Address, City, State)
Course of Study
Number of Years Completed
Degree/Major*
Graduate*
YesNo
Honors Received
Certifications

WORK EXPERIENCE

Please list the names of your present and/or previous employers in chronological order with present or most recent employer listed first. Provide information for at least the most recent ten (10) year period. If self-employed, supply firm name and business references. You may include any verifiable work performed on a volunteer basis, inte
ships, or military service. Your failure to completely respond to each inquiry may disqualify you for consideration of employment. DO NOT ANSWER SEE RESUME.

1

Most Recent Employer - Name and Location (Address, City, State)*
Type of Business*
Telephone Number*
Dates Employed - From (Month/Day/Year)*
Dates Employed - To (Month/Day/Year)*
Job Title*
Duties*
Supervisor's Name*
May We Contact*
YesNo
Wages - Start*
Wages - Final*
Reason for Leaving*
What will this employer say was the reason your employment termination?*
How much notice did you give when resigning? If none, explain.*

2

Employer - Name and Location (Address, City, State)*
Type of Business*
Telephone Number*
Dates Employed - From (Month/Day/Year)*
Dates Employed - To (Month/Day/Year)*
Job Title*
Duties*
Supervisor's Name*
May We Contact*
YesNo
Wages - Start*
Wages - Final*
Reason for Leaving*
What will this employer say was the reason your employment termination?*
How much notice did you give when resigning? If none, explain.*

3

Employer - Name and Location (Address, City, State)*
Type of Business*
Telephone Number*
Dates Employed - From (Month/Day/Year)*
Dates Employed - To (Month/Day/Year)*
Job Title*
Duties*
Supervisor's Name*
May We Contact*
YesNo
Wages - Start*
Wages - Final*
Reason for Leaving*
What will this employer say was the reason your employment termination?*
How much notice did you give when resigning? If none, explain.*

4

Employer - Name and Location (Address, City, State)
Type of Business
Telephone Number
Dates Employed - From (Month/Day/Year)
Dates Employed - To (Month/Day/Year)
Job Title
Duties
Supervisor's Name
May We Contact
YesNo
Wages - Start
Wages - Final
Reason for Leaving
What will this employer say was the reason your employment termination?
How much notice did you give when resigning? If none, explain.
Please Explain Any Lapses in Employment

REFERENCES

Please list the names of additional work-related references we may contact. Individuals with no prior work experience may list school or volunteer-related references.

Name*
Position
Company
Work Relationship (supervisor, co-worker)*
Telephone Number
Email

Name*
Position
Company
Work Relationship(supervisor, co-worker)*
Telephone Number*
Email

Please list the names of Personal References (not previous employers or relatives) who know you well enough that we may contact.

Name*
Occupation
Address
Years Known*
Telephone Number*
Email Address*

Name*
Occupation
Address
Years Known*
Telephone Number*
Email Address*

APPLICANT CERTIFICATION

I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver's license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside. I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that all employees of the location, pursuant to the Company's policy and federal, state, and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs. If employed, I understand that the taking of alcohol and/or drug tests is a condition of continued employment and I agree to undergo alcohol and drug testing consistent with the Company's policies and applicable federal, state, and local law. If employed by the Company, I understand and agree that the Company, to the extent permitted by federal, state, and local law, I may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement. I certify that all the information on the application, my resume, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal. THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THE APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT--EXPRESS OR IMPLIED--WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY. IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME. EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL. I authorized the Company or its agents to confirm all statements contained in this application and/or resume as it relates to the position I am seeking to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation which may be permitted by federal, state, or local law. If applicable and allowed by law, I will receive separate written notification regarding the Company's intent to obtain "consumer reports." I authorize and consent to, without reservation, any party or agency contacted by this employer to fu
ish the above-mentioned information. I hereby release, discharge and hold harmless, to the extent permitted by federal, state, or local law, any party delivering information to the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations fu
ishing such information. Further, if hired, I authorize the company to provide truthful information conce
ing my employment to future employers and hold the company harmless for providing such information. If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Company. I also understand this Company employs only individuals who are legally eligible to work in the United States. THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY. I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE. DO NOT SIGN UNTIL YOU HAVE READ ALL OF THE INFORMATION CONTAINED IN THE APPLICATION.

Applicant Signature*
Date(Month/Day/Year)*

If the applicant is a minor, the foregoing release and consent must be signed by the applicant's parent or legal guardian. Signature by the applicant's parent or legal guardian constitutes acknowledgement by the applicant and the parent or legal guardian that the Company, to the extent permitted by federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate test results to Company personnel who need to know, the applicant, and the applicant's legal guardian.

Parent Signature*
Witness Signature*