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APPLICATION FOR EMPLOYMENT

An Equal Opportunity Employer

We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any otherstatus protected by law or regulation. It is our intention that all qualified applicants be given equal opportunityand that selection decisions be based on job-related factors.

First name

Last name

Phone

Position

Start Date

Month

Day

Year

UPLOAD RESUME (optional)

Are you seeking:

FULL TIME

PART TIME

TEMPORARY

Are you 21 years of age or older?

YES

SOCIAL SECURITY NUMBER:

If hired, can you furnish proof you are eligible to work in the U.S.?

YES

Have you ever applied here before?

YES

Have you ever been convicted of any law violation?

YES

If employed, do you expect to be engaged in any additional business or employment outside of our job?

YES

LIST NAME SCHOOLS

High School or GED:

College or University:

Vocational or Technical:

What skills or additional training do you have that relate to the job for which you are applying?

What machines or equipment can you operate that relate to the job for which you are applying?

List names of employers in consecutive order with present or last employer listed first.

NAME OF EMPLOYER

JOB TITLE AND DUTIES

Address

SUPERVISOR(S)

TELEPHONE

DATES OF EMPLOYMENT (MO/YR):

FROM

PAY:

START $

FINAL $

Reason For Leaving

NAME OF EMPLOYER

JOB TITLE AND DUTIES

Address

SUPERVISOR(S)

TELEPHONE

DATES OF EMPLOYMENT (MO/YR):

FROM

PAY:

START $

FINAL $

Reason For Leaving

NAME OF EMPLOYER

JOB TITLE AND DUTIES

Address

SUPERVISOR(S)

TELEPHONE

DATES OF EMPLOYMENT (MO/YR):

FROM

PAY:

START $

FINAL $

Reason For Leaving

Are you presently employed?

YES

Have you ever been fired from a job or asked to resign?

YES

Give three references, not relatives or former employers

NAME

PHONE

ADDRESS

NAME

PHONE

ADDRESS

NAME

PHONE

ADDRESS

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in

making such statements.

I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required.

I understand that if I am extended an offer of employment, it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which 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 ORGANIZATION HAS THE AUTHORITY

TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE PRESIDENT AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.

I have read, understand, and by my signature consent to these statements.

Signature

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