Application for Employment

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other protected status.

Position applied for:   How did you hear about us:
Last Name:   First Name:   Middle Initial:
Address:   City:   State:   Zip:
E-Mail Address:

Are you over the age of 18? yes  no
(If no, you may be required to provide authorization to work.)
Have you ever filed an application with us before? yes  no  If yes, give date
Have you ever been employed by this company before? yes  no  If yes, give date
Are you currently employed? yes  no
May we contact your your present employer? yes  no
Wage desire?
Are you legally eligible to be employed in the United States? yes  no
(Proof of identity and eligibility will be required upon employment)
When are you available to begin work?
Are you available to work: Full Time Part Time  Shift Work  Days  Nights
Can you travel if the job requires it? yes  no
Have you been convicted of a felony within the last 7 years? yes  no

Conviction will not necessarily disqualify an applicant from employment
If yes, please explain including dates and nature of conviction:

Employment Experience

Begin with most recent employment [1] and continue with all past employment for past 10 years.
 

Employer:   Address:
Telephone Number:   Job Title:   Supervisor:
Work Performed:   Reason for Leaving:
Dates Employed: Start Ending
Hourly Rate: Start   Ending     or  Salary Starting   Ending


Employer:   Address:
Telephone Number:   Job Title:   Supervisor:
Work Performed:   Reason for Leaving:
Dates Employed: Start Ending
Hourly Rate: Start   Ending     or  Salary Starting   Ending


Employer:   Address:
Telephone Number:   Job Title:   Supervisor:
Work Performed:   Reason for Leaving:
Dates Employed: Start Ending
Hourly Rate: Start   Ending     or  Salary Starting   Ending


Employer:   Address:
Telephone Number:   Job Title:   Supervisor:
Work Performed:   Reason for Leaving:
Dates Employed: Start Ending
Hourly Rate: Start   Ending     or  Salary Starting   Ending

List professional, trade, business or civic activities and offices held.
*You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:

Education

High School
Name of School:   Location:
Received: diploma  other    If other, please explain:
Your name if different while attending school:


College, University or Professional School
Name of School:   Dates of Study: Location:
Major/Minor Course of Study: Type of Degree Earned:
Your name if different while attending school:


Name of School:   Dates of Study: Location:
Major/Minor Course of Study: Type of Degree Earned:
Your name if different while attending school:


Name of School:   Dates of Study: Location:
Major/Minor Course of Study: Type of Degree Earned:
Your name if different while attending school:

Indicate any foreign languages you can speak, read and/or write:

To your knowledge, are any of your relatives employed by this company? yes  no
If yes, please list name and department:

Additional Information

Summarize special job-related skills and qualifications acquired from employment. Please indicate any prior military training which you would like considered in connection with your application for employment.

Please list any specialized skills:

State any additional information you feel may be helpful to us in considering your application.

Can you perform the essential functions of the position for which you are applying. (If you have any questions as to what functions are applicable to the position for which you are applying, please ask interviewer before you answer this question. yes  no

References
Give three individuals (not relatives or employers)

Name:   Phone:
Address:


Name:   Phone:
Address:


Name:   Phone:
Address:



I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE, I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

Questions regarding this statement should be directed to any employment interviewer before submitting. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

It is the policy of the company to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status, expunged juvenile records, or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, and any other characteristic protected by Federal, State or Local law.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.

If hired, I agree to abide by all of the company rules and regulations, and understand that, if employed, my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either the company or me, I further understand that no representation, whether oral or written by any representative or agent of the company, at any time, can constitute a contract of employment. I understand that the company and all Plan Administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment. No representative or agent of the company, has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the President , or to make any agreement contrary to the foregoing.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me.