Application for Employment

• * First Name
• Middle Initial
• * Last Name
• Upload Resume
• * Street Address
• * City
• * State
• * Zip Code
• * Email Address
• * Phone (Home)
• Phone (Cell)
• Phone (Other)
• If under 18, do you have a work permit? Yes No
• If you have ever worked under another name, please identify.

• * Desired Position
• * Date you can start work
• * Expected Starting Salary/Wage
• * Availability (check all that apply) Full time
  Part time
  Evenings
  Weekends
• * Any days/time you cannot work?
• * How did you learn of this job opening?
• * Have you ever worked here before? Yes No
• If yes, when?
• Who was your supervisor?
• Why did you leave?
• Know anyone that works here? Who?

• * Highest Grade Completed 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 1 2 3 4
• * Last School Attended
• * Any Relative Special Skills?

• * Are you currently employed? Yes No
• * Are you on layoff and subject to recall? Yes No
• If yes, to where?
• Describe your employment experiences below beginning with your present or most recent employers.
• Employer #1
• * Present or Last Employer
• * Address
• * Type of Business
• * Phone
• * Starting Position
• * Starting Pay
• * Final Position
• * Final Pay
• * Month/Year Employed From and To
• * Name & Title of Supervisor
• * Work & Responsibilities Description
• * Reason for Leaving
• * Will you receive a satisfactory reference from this employer?
  If no, please explain.
• * May we contact your present employer?
  If no, please explain.
• Employer #2
• Present or Last Employer
• Address
• Type of Business
• Phone
• Starting Position
• Starting Pay
• Final Position
• Final Pay
• Month/Year Employed From and To
• Name & Title of Supervisor
• Work & Responsibilities Description
• Reason for Leaving
• Will you receive a satisfactory reference from this employer?
  If no, please explain.
• May we contact your present employer?
  If no, please explain.
• Employer #3
• Present or Last Employer
• Address
• Type of Business
• Phone
• Starting Position
• Starting Pay
• Final Position
• Final Pay
• Month/Year Employed From and To
• Name & Title of Supervisor
• Work & Responsibilities Description
• Reason for Leaving
• Will you receive a satisfactory reference from this employer?
  If no, please explain.
• May we contact your present employer?
  If no, please explain.

• * Do you have, or have you applied for, the legal right to remain permanently and work in the US? Yes No
• * Have you ever been discharged or asked to resign by an employer? Yes No
• If yes, please explain.

A record of criminal conviction will not necessarily be a bar to employment, since the Company will consider factors such as age, time of the offense, the nature and seriousness of the violation, and the evidence of rehabilitation in making any employment decision.

• * Been convicted of a crime
  (other than minor traffic violations)? Yes No
• If yes, please explain.

Please complete this section if the job for which you are applying might require you to drive Company vehicles.

• Have a valid driver's license? Yes No
• License number and state
• Any driving accidents in last 5 years? Yes No
• If yes, please explain

• * Served in the US Armed Services? Yes No
• What branch?
• Describe any skills you acquired in the Service which would be useful to the job for which you are applying:

Completing this section of the application is optional. Leave this section blank if you do not wish to answer.

List the names of three professional or personal character references who have known you for the last three years and from whom you can obtain letters of recommendation. Please do not list relatives.

• Reference #1
• Name
• Address
• Phone
• Relationship
• Reference #2
• Name
• Address
• Phone
• Relationship
• Reference #3
• Name
• Address
• Phone
• Relationship

By signing below, I certify that I have read, understand and agree to each of the following statements.

All of the information I have supplied on this application is true, accurate and complete, to the best of my knowledge, and I have not knowingly withheld any information which, if known to the company, would affect my application unfavorably.

If I am hired by the company, and if the company discovers at any time during my employment that any of the statements or answers on this application are false, misleading, or incomplete, I may be dismissed immediately from the job.

This employment application will be considered active for ninety (90) days from the date received by the company. If I want to be considered for a job with the company after this period of time I must fill out another application.

I agree to submit to a medical examination which may include testing for drugs or alcohol prior to beginning work with the company. I understand that if I am employed by the company, I may be required, when job related and consistent with the company's business needs, to undergo a medical examination or testing for alcohol. I further understand that I may be required to submit to a test for the use of illegal drugs at any time.

In consideration of my employment with the company, I agree to abide by all the company's rules and regulations.

I understand that nothing in this employment application creates a contract of employment between me and the company. If I am hired by the company, my employment and compensation are "at will", which means that my employment can be terminated, either by the company or me, with or without cause, and with or without notice. I understand that no manager or supervisor has the authority to make any employment agreement with me, either orally or in writing, that is not an at-will agreement. Only the President of the company has the authority to enter into an employment agreement with me for any specified period of time.

I agree to release to the company or its designated agents all medical information, including but not limited to files, reports, x-rays, evaluations, and opinions held by medical personnel, to the extent such information is job-related and consistent with the company's business needs. I acknowledge that this is a general release and that if hired, it remains in effect for the duration of my employment.

In the event of my personal indebtedness to the company, I authorize the company to withhold from my wages such amounts as permitted by law to satisfy my obligation to the company.

I give the company my permission to conduct any investigation regarding the information contained in my employment application, which the company thinks is necessary to determine my qualifications for assuming a job with the company. I give the company my permission to contact any former employer, school, college or university, utility company, credit or finance bureau or office, any personal or professional reference, or any other appropriate source or individual for the purpose of gathering any information, personal or otherwise, that such sources may have about my character, general reputation, credit, education, or employment record, and I give my consent to any such source to release to the company whatever information they have about me. I also unconditionally release all named and unnamed sources from any and all liability which might result from furnishing any information about me.

• * Electronic Signature (type your name)