APPLICATION FOR EMPLOYMENT A n Equal Opportunity Employer W e do not discriminat e on t he basis of race, color, religion, nat ional origin, sex, age, disabilit y, genet ic inf ormat ion or any ot her st atus prot ect ed by law or regulation. It is our intention that all qualified applicants are given equal opportunity and that selection decisions be based on job-related factors. G Answ er each quest ion f ully and accurat ely. No act ion can be t aken on t his applicat ion unt il you have answ ered all quest ions. Use blank paper if you do not have enough room on t his applicat ion. PLEASE PRINT, except f or signat ure on back of applicat ion. In reading and answ ering t he f ollow ing quest ions, be aw are t hat none of t he quest ions are int ended t o imply illegal pref erences or discriminat ion based upon non-job-relat ed inf ormat ion. E N E R Job Applied f or A Are you seeking: Full-t ime L Today’ s Dat e Part -t ime Last Name Temporary First Name employment ? When could you st art w ork? Middle Name Present St reet Address Cit y Telephone Number St at e Zip Code Are you 1 8 years of age or older? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No Yes No Yes No Yes No (If you are hired, you may be required t o submit proof of age.) If hired, you w ill be required t o f urnish proof of your eligibilit y t o w ork in t he U.S. Have you ever applied here bef ore? Yes No If yes, w hen? Were you ever employed here? Yes No If yes, w hen? Have you ever been convict ed of any law violat ion in t he last seven years? Include any plea of “ guilt y” or “ no cont est .” (Exclude minor t raf f ic violat ions.) . . . . . . . . . . . . . . . . . . . . . If yes, give det ails (A convict ion w ill not necessarily disqualif y an applicant f or employment .) If employed, do you expect t o be engaged in any addit ional business or employment out side of our job? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, give det ails For Driving Jobs Only: Do you have a valid driver’ s license? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Driver’ s License Number Class of License St at e Licensed In Have you had your driver’ s license suspended or revoked in t he last 3 years? . . . . . . . . . . . . . . . Yes No If yes, give det ails: E D U C A T I O N LIST NAM E AND ADDRESS OF SCHOOLS Number of Years Complet ed Diploma/ Degree/ Cert if icat e High School or GED: College or Universit y: Vocat ional or Technical: What skills or addit ional t raining do you have t hat relat e t o t he job f or w hich you are applying? What machines or equipment can you operat e t hat relat e t o t he job f or w hich you are applying? Subject s St udied names of employers in consecut ive order w it h present or last employer list ed f irst . Account f or all periods of t ime W List including milit ary service and any periods of unemployment . If self -employed, give f irm name and supply business ref erences. O R K H I S T O R Y Not e: A job of f er may be cont ingent upon accept able ref erences f rom current and f ormer employers. NAME OF EMPLOYER JOB TITLE AND DUTIES ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM CITY, STATE, ZIP CODE SUPERVISOR(S) PAY: START $ TELEPHONE Reason For Leaving JOB TITLE AND DUTIES ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM SUPERVISOR(S) PAY: START $ TELEPHONE Reason For Leaving JOB TITLE AND DUTIES ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM SUPERVISOR(S) PAY: START $ TELEPHONE Reason For Leaving JOB TITLE AND DUTIES ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM SUPERVISOR(S) PAY: START $ TELEPHONE TO FINAL $ NAME OF EMPLOYER CITY, STATE, ZIP CODE TO FINAL $ NAME OF EMPLOYER CITY, STATE, ZIP CODE R FINAL $ NAME OF EMPLOYER CITY, STATE, ZIP CODE TO TO FINAL $ Reason For Leaving Have you w orked or at t ended school under any ot her names? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes If yes, give names: E F Are you present ly employed?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes E If yes, w hom do you suggest w e cont act ? R E Have you ever been f ired f rom a job or asked t o resign? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes N If yes, please explain: C Give t hree ref erences, not relat ives or f ormer employers. E Name Address Phone S No No No PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING I cert if y t hat all inf ormat ion provided in t his employment applicat ion is t rue and complet e. I underst and t hat any f alse inf ormat ion or omission may disqualif y me f rom f urt her considerat ion f or employment and may result in my dismissal if discovered at a lat er dat e. I aut horize t he invest igat ion of any or all st at ement s cont ained in t his applicat ion. I also aut horize, w het her list ed or not , any person, school, current employer, past employers and organizat ions t o provide relevant inf ormat ion and opinions t hat may be usef ul in making a hiring decision. I release such persons and organizat ions f rom any legal liabilit y in making such st at ement s. I underst and I may be required t o successf ully pass a drug screening examinat ion. I hereby consent t o a pre- and/or post -employment drug screen as a condit ion of employment , if required. I underst and t hat if I am ext ended an of f er of employment it may be condit ioned upon my successf ully passing a complet e pre-employment physical examinat ion. I consent t o t he release of any or all medical inf ormat ion as may be deemed necessary t o judge my capabilit y t o do t he w ork f or w hich I am applying. I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZA TION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN W RITING, SIGNED BY THE PRESIDENT AND THE EM PLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, W ITH OR W ITHOUT REASON AND W ITH OR W ITHOUT NOTICE. I have read, underst and, and by my signat ure consent t o t hese st at ement s. Signat ure: Dat e: This applicat ion f or employment w ill remain act ive f or a limit ed t ime. Ask t he organizat ion’ s represent at ive f or det ails.