Employment Application

Personal Information

Name *

SSN *

Phone Number *

Email *

Address *

City *

State *

Zip Code *

Date of application

Have you ever worked or attended school using any other name?*YesNo

If yes, what is the name *

Dates known by this name *

Have you ever been convicted of a felony?*YesNo

If Yes, describe in full

Do You have, or can you obtain the necessary documents that would permit you to work in the United States?*YesNo

Are you over age 18?*YesNo

Do any of your friends or relatives work here?*YesNo

Have you filled an application here before?*YesNo

Date if yes

Position applied for *

Status Desired*Full TimePart Time

Date available

List my skills, qualifications, courses or training you have that relate to the position for which you are applying:*

If there are any hours you are unwiling to work what are they?* *

Are you on lay-off and subject to recall?*YesNo

Driving Record

Do you Presently have a valid driver's license?*YesNo

If yes list the following driver’s license information:

State*

Number*

Type*

Expiration date

Have You had an accident or moving violation within the past 5 years?YesNo

If yes describe in full.

Record Of Education

School*

Address*

Course of Study*

Select last year completed*1234

Did you Graduate?*YesNo

List Diploma or Degree*

Are you a veteran of the U.S. Military Service?*YesNo

If yes, what branch of U.S. Military Service?

Are you presently a member of the Military Reserve or National Guard?*YesNo

List Professional, Trade, Business or Civic activities and office held.*

Present And Past Employment (Begin with most recent)

Employer 1

Company Name*

From*

To*

Describe the work you did:*

Weekly starting Salary:*

weekly last salary:*

Reason for leaving:*

Name Of Supervisor:*

Phone Number:*

Employer 2

Company Name*

From*

To*

Describe the work you did:*

Weekly starting Salary:*

weekly last salary:*

Reason for leaving:*

Name Of Supervisor:*

Phone Number:*

Employer 3

Company Name*

From*

To*

Describe the work you did:*

Weekly starting Salary:*

weekly last salary:*

Reason for leaving:*

Name Of Supervisor:*

Phone Number:*

May we contact the employers listed above?*YesNo

If not, indicate which one(s) you do not wish us to contact and state the reason why not:

Have you ever been bonded?*YesNo

If yes Where?

Give name, address and phone number of three references not related to you:*

If required for the position for which you are applying, will you consent to a post offer pre-employment physical examination and blood or urine analysis at company expense?* (Note: the analysis may test for controlled substances.)YesNo

What was the reason?*

When is the last time you a missed a week of work or school for a reason other than illness, injury or disability?*

Have you ever signed any type of agreement that may in any way restrict your performance of services with this company?*YesNo

Do you understand that if employed your attendance record must meet the requirements set by the company?*YesNo

If yes explain:

Agreement

(Please Read Carefully)

This Company is an equal employment opportunity employer. Federal law prohibits discrimination in employment practices because of race, color, religion, sex, national origin, citizenship status, age or disability if otherwise qualified.

I certify that all of the information given by me on this application or in supplemental form is true and correct to the best of my knowledge and belief. I further understand that false or misleading statements or consequential omissions of any kind on this application or supplemental forms are sufficient cause for my not being hired or my dismissal if I am hired.

I understand that if I am offered employment, such offer may be conditioned upon my taking a pre-employment physical. I understand that if I falsify responses to medical inquiries, including my history of workers’ compensation claims, I may be terminated from employment and precluded from receiving worker’s compensation benefits. I understand that I may be tested for controlled substances from time to time and that a positive test may be grounds for termination and denial of worker’s compensation and/or unemployment benefits. Further, I understand that any employee or former employee who makes knowingly false or fraudulent material statements or misrepresentation for the purpose of obtaining worker’s compensation benefits may be guilty of a felony.

I agree, understand and authorize that this Company or its agents may investigate my background to ascertain any and all information of concern to my record, whether same is of record or not. I authorize the persons or organizations referenced in this application to give the Company any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application and I release all such parties from all liability from any damage that may result from furnishing such information to this Company.

I also agree and understand that under the Fair Credit Reporting Act I have been told that this investigation may include an investigative consumer report, including information regarding my character, general reputation, personal characteristics and mode of living. If any such investigation results in denial of employment, I shall be so advised. The Company shall supply the name and address of the consumer reporting agency making the investigative report, and I will be given an opportunity to correct any misinformation contained in any such report.

I agree and understand that the Company may require that I be approved for bonding as a condition of my employment. Further, I will comply with the Company’s security policies and other policies, rules and procedures that may be established by the Company from time to time.

It is agreed and understood that this Application for Employment in no way obligates the Company to employ me. If employed, I agree and understand that my employment is for no definite duration and may be terminated at will by either the Company or me. It is agreed and understood by me that participation in any of the benefit programs of the Company does not create a contract of employment for a definite period of time. Additionally, The Employment Handbook or other statements of Company policy is not a contract and cannot create a contract of employment for any definite duration.

In the event of my employment, any Company materials entrusted to me during the course of my employment will be returned to the Company on the last day of my employment, whether I resign or be terminated. I agree and understand that should I be employed, I will not at any time or in any manner, either directly or indirectly, divulge, disclose or communicate to any person, firm or corporation any matters affecting or relating to the business of the employer, including, without limiting the generality of the foregoing, any of its customers, the prices it attains or has attained from the sale of, or which it sells or has sold, its services or products, its manner of operation, its plans, and any other “proprietary information”. I understand that I may be asked to sign a confidentiality agreement consistent with this paragraph as a condition of employment.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete, to the best of my knowledge.

Date

Signature *

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