Job Applied For (required)

Today's Date (required)

Type of Employment: (required)

Full-TimePart-TimeTemporary

When could you start work? (required)

First Name (required)

Middle Name (if applicable)

Last Name (required)

Telephone Number (required)

Email (required)

Present Street Address (required)

City (required)

State (required)

Zip Code (required)

Are you 18 years of age or older? (required; If you are hired, you may be required to submit proof of age.)

YesNo

Social Security Number (required)

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

YesNo

Have you ever been hired here before? (required)

YesNo

If yes, when? (required, if answered yes above)

Were you employed here? (required)

YesNo

If yes, when? (required, if answered yes above)

Are you subject to a non-compete agreement? (required)

YesNo

Have you been convicted of any law violation (except minor traffic violations)? (required)

YesNo

If yes, give details (required, if answered yes above)

(A "Yes answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying is also considered.)

Are you now of do you expect to be engaged in any other business or employment? (required)

YesNo

If yes, please explain (required, if answered yes above)

Education

High School or GED (required)

Number of Years Completed (High School or GED)

Diploma/Degree/Certificate (High School or GED)

College or University (if applicable)

Number of Years Completed (College or University)

Diploma/Degree/Certificate (College or University)

Vocational or Technical (if applicable)

Number of Years Completed (Vocational or Technical)

Diploma/Degree/Certificate (Vocational or Technical)

Special Skills

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

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

How many days of work have you missed during the past year? (required; Exclude absenses due to disability or those covered by FMLA)

For Driving Jobs Only:

Do you have a valid driver's license?

YesNo

Driver's License Number

Class of License

Have you had your driver's license suspended or revoked in the last 3 years?

YesNo

If yes, give details (required if answered "Yes" above)

List professional, trade, business, or civic activities and offices held. (Exclude labor organizations and memberships which reveal race, color, religion, national origin, sex, age, disability, or other protected status.)

Employment History

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references.

Employer #1

Name, Address, & Telephone (Employer #1)

Job Title (Employer #1)

Supervisor (Employer #1)

Employed Date (Employer #1)

Starting Compensation (Employer #1)

Final Compensation (Employer #1)

Reason for Leaving (Employer #1)

Duties (Employer #1)

Employer #2

Name, Address, & Telephone (Employer #2)

Job Title (Employer #2)

Supervisor (Employer #2)

Employed Date (Employer #2)

Starting Compensation (Employer #2)

Final Compensation (Employer #2)

Reason for Leaving (Employer #2)

Duties (Employer #2)

Employer #3

Name, Address, & Telephone (Employer #3)

Job Title (Employer #3)

Supervisor (Employer #3)

Employed Date (Employer #3)

Starting Compensation (Employer #3)

Final Compensation (Employer #3)

Reason for Leaving (Employer #3)

Duties (Employer #3)

Employer #4

Name, Address, & Telephone (Employer #4)

Job Title (Employer #4)

Supervisor (Employer #4)

Employed Date (Employer #4)

Starting Compensation (Employer #4)

Final Compensation (Employer #4)

Reason for Leaving (Employer #4)

Duties (Employer #4)

References

Have you worked or attended school under any other names? (required)

YesNo

If yes, give names: (required if answered "Yes" above)

Are you presently employed? (required)

YesNo

If yes, whom do you suggest we contact? (required if answered "Yes" above)

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

YesNo

If yes, please explain: (required if answered "Yes" above)

Give three references, not relatives or former employers

Name (Reference #1) (required)

Address (Reference #1) (required)

Phone (Reference #1) (required)

Name (Reference #2) (required)

Address (Reference #2) (required)

Phone (Reference #2) (required)

Name (Reference #3) (required)

Address (Reference #3) (required)

Phone (Reference #3) (required)

AFFIDAVIT

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 understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a
complete disclosure of the nature and scope of the investigation.

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 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 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 THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. 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 CAUSE AND WITH OR WITHOUT NOTICE.

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

Electronic Signature:

Date:

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