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APPLICATION FOR EMPLOYMENT AN EQUAL OPPORTUNITY EMPLOYER Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. Use blank paper if you do not have enough room on this application blank. PLEASE PRlNT except for signature on back of Application. All information given will be held in strict confidence. This application is current only for thirty (30) days, at the conclusion of which time, if you have not heard from us and still wish to be considered for employment, it will be necessary for you to fill out a new application. NAME (Print) _______________________________________________________________________________________________ TODAYS DATE______________________ Last Middle First PRESENT ADDRESS _______________________________________________________________________________________ No. Street City State Zip TELEPHONE NO _______________________________________ CELL NO __________________________________________ Job applied for? ____________________________________ When are you available for employment_______________________ RECORD OF EMPLOYMENT Name of Current/Most Recent Employer DATE EMPLOYED Address Telephone RATE OF PAY Starting Ending Reason for Leaving Type of Business Supervisor’s Name and Title From To Mo. Yr. Mo. Yr. List the jobs held, duties performed, skills used or learned, advancements or promotions. Name of Current/Most Recent Employer DATE EMPLOYED Address Telephone RATE OF PAY Starting Ending Reason for Leaving Type of Business Supervisor’s Name and Title From To Mo. Yr. Mo. Yr. List the jobs held, duties performed, skills used or learned, advancements or promotions. Name of Current/Most Recent Employer DATE EMPLOYED Address Telephone RATE OF PAY Starting Ending Reason for Leaving From To Mo. Yr. Mo. Yr. List the jobs held, duties performed, skills used or learned, advancements or promotions. Over/Next Page Type of Business Supervisor’s Name and Title Are you seeking: Full-time Part-time Temporary or Summer Have you ever been convicted of a criminal offense? Yes No employment? (A conviction will not necessarily disqualify an applicant) If yes, please explain: _______________________________________________________________________________________ Are you over 18 years of age? Yes No Are you a citizen of the United States or do you have a valid work permit? Yes No Federal Law requires proof of identity and employment authorization for all new employees. Do you have a valid driver’s license? Yes No EDUCATION Circle last year completed: School Name Major Subjects High School 1 2 3 4 _____________________________________________ ________________________ College 1 2 3 4 _____________________________________________ ________________________ Other (Business, Vocational, Military)_________________________________________________________________________ IF you are an experienced operator of any business/plant machines or equipment, please list: _______________________________________ Other Skills __________________________________________________________________ ________________________ __________________________________________________________________ ________________________ __________________________________________________________________ ________________________ __________________________________________________________________ ________________________ Are you capable of performing, with or without a reasonable accommodation, the essential factions of the job or occupation for which you have applied? May we contact your present employer? Yes No CERTIFICATION This Employment Application is used to notify me that the nature and scope of an investigation, if one is conducted, could include such general identification information as residence verification, and as applicable, information concerning my employment, education, general reputation, character, personal characteristics, and habits, and that such information may be developed through personal interviews with third parties such as family members, neighbors, friends, associates, former employers, financial sources, and custodians of official records. Only job-related information developed from such a report will be considered in evaluation my employment application or continued employment. I hereby authorize these persons, companies, organizations or corporations to answer all questions or release any information regarding the items listed in this paragraph. I hereby release them from any liability and hold them harmless from any claim for releasing any truthful information within their knowledge and/or records. I authorize the Company to release to any person, firm, entity or organization with which I may seek employment in the future, any truthful information concerning my work experience with the Company. I hereby release and hold the Company harmless from any claim for releasing any truthful information within its knowledge and/or records. I understand that any job offer that may be extended to me will be contingent upon the successful completion of a drug and alcohol test. I understand that neither this application nor any written personnel procedure manual or employee handbook is an express or implied contract of permanent employment. I further understand that my relationship with the Company is at-will and for an unspecified term and that the Company and I each have the right to terminate the employment relationship at any time, with or without cause or advance notice. My signature below certifies that all information in this application is correct and complete to the best of my knowledge and belief and that I understand that intentionally false information will result in refusal of employment or termination of employment if discovered after date of hire. I also authorize the employers, schools, or persons named above to provide information regarding my employment, education, character, and qualifications. I have had an opportunity to have my questions about this statement’s content and intent answered and understand its terms. Signature____________________________________________________________ Date ________________________________