PROVIDE ALL / ONLY INFORMATION REQUESTED OR YOU MAY BE DISQUALIFIED.

SECTION 1: Personal Information

Please enter your full name (First Name Last Name, Middle Initial, eg. John Smith, M.):

Address (Street, City, State, Zip):

Telephone:

Primary Email address (you'll receive a copy of the filled out Application to this email):

Are you under 19 years old? YesNo

If yes, state your date of birth:

Are you lawfully authorized to work in the United States? YesNo

If you are related to any of our employees, please state the name of the employee and the employee’s position with Employer, if known (Full name, Position):

For what position(s) are you applying?

Date available for work:

Are you on layoff and subject to recall? YesNo

What are you willing to work?
Part timeFull timeTemporary

If temporary, please specify dates (from-to):

List days of week & hrs of day you can’t work:

Do you have any commitments that will necessitate your absence from work during regular work hours for more than three consecutive days within the next six months?
YesNo

If yes, please explain:

Will you work over 40 hrs/week if required? YesNo

Will you accept out-of-town assignments if required? YesNo

Why do you want this job?

SECTION 2: Job Requirements (Complete this Section only if you have been told the job qualifications/requirements):

I meet all required educational, experience & certification/license qualifications of the job:
YesNo

If no, what qualifications do you lack:

I have reviewed the essential job functions and state that I can perform these functions with or without reasonable accommodation.
YesNo

SECTION 3: Employment History

List chronologically every employer during the past 10 years beginning with most current. Do Not Omit any prior employment within this period. Explain any gaps in your work history that are longer than six months. Please use this format: Date (from-to), Name & Address of Employer, Last Position, Reason for Leaving

Have you ever been fired from a job or quit under threat of being fired? YesNo

If yes, please specify When, Who was the Employer, and reason for dismissal or forced designation:

Please describe any problems in your current job about which you have been warned or disciplined during the past 12 months:

Who should we contact to confirm current employment data? (Name, Title, Phone number)

Can we talk to your current employer now, or only if you are hired?
YesNoOnly if hired

Have you ever been employed by us before? YesNo

If yes, please state the positions held, period of employment and reason for leaving:

SECTION 4: Education

Please specify: Name of school, Location, Year of graduation, Major subjects)

High School

College:

Technical or Graduate School:

What special training or skills do you have for this job position?

SECTION 5: Criminal Record

Have you been convicted of or plead guilty (includes also deferred judgment and no contest plea) to a crime or subjected to court martial? (Do not include crimes for which public records are sealed or have been expunged)

YesNo

If “Yes,” identify nature of the offense, county and state where convicted, date of conviction, and sentence or fine imposed.

If you are presently charged with committing a criminal offense, please identify: nature of offense, county and state where charges are pending, and status of the charges:

SECTION 6: Illegal Drugs

Within the past 60 days, have you used marijuana, cocaine, any narcotics, amphetamines, barbiturates, or other controlled substances that were not taken as prescribed to you by a physician?

YesNo

SECTION 7: Personal References (no relatives)

Please enter three people with their full Name, Address, Phone number Relationship to you, and years Acquainted:

PLEASE READ THE FOLLOWING PARAGRAPH BEFORE SIGNING THIS APPLICATION

I certify that the information in this application is correct to the best of my knowledge. I understand that any misrepresentation of information by statement or omission will result in disqualification or, if already hired, dismissal from employment, no matter when the misrepresentation is discovered. I authorize Employer to contact my references, investigate my employment history, education, and if applicable, driving record. I agree to assist Employer in obtaining background information on me by signing any authorization/release forms necessary to obtain such information. I will submit to and pass any drug test required by Employer as a condition of employment. All employment with Employer is at-will, meaning that employment with Employer may be terminated, with or without cause, and with or without prior notice, at any time, at the option of either me or the Employer. I understand that no supervisor or manager has the authority to enter into an agreement for employment that waives Employer’s right to terminate employment at will. I understand that Employer has policies and procedures that I must follow, if hired. I understand that Employer reserves the right to change its policies and procedures, including personnel policies and employee benefits at any time without approval by employees, and that these changes are accepted by continuing my employment with Employer. I certify that I am submitting this application because of a good faith desire for employment with Employer. If offered employment, I will consider the offer, and if I accept, I will fulfill the requirements of the job to the best of my ability.

I have Read, Understand and Accept the above statements.