Last Name:  First Name:  Middle Initial: 

Other Name(s) Used: 

Address:  City:   State:  Zip Code:

Phone Number: Alternate Phone:    Email Address:

A valid email address is required for submission of form...

Position applying for:     Referred By:    Salary Desired:

Have you ever interviewed with this company before?  yes   no

If yes, list date(s), job title(s), & location(s):  

Have you ever been employed by the Company or it's affiliates before?   yes   no

If yes, list date(s), job title(s), and location(s):

Do you have any relatives employed by the Company or it's affiliates?   yes     no

If yes, list date(s), job title(s), and location(s):  

Are you at least 18 years old?  yes    no             If under 18, do you have a work permit?   yes    no

Education:

Select Highest Grade Completed:  

High School  9th    10th    11th    12th                          College    1    2    3    4

High School Name:                         College / University Name:

Address:                        Address:   

Diploma and/or GED:  yes    no                                               Certificate and/or Degree:   yes    no

Please list any professional designations:              

Other special knowledge, skills, or qualifications:

Employment History:

Employment Dates:    from  to

Employer Name:       

Employer Address:  

Starting Salary:      Ending Salary:      Job Title:

Supervisor Name:  Supervisor Phone:  

Duties and Responsibilities:

Reason for leaving:  - 

Employment Dates:    from  to

Employer Name:       

Employer Address:  

Starting Salary:      Ending Salary:      Job Title:

Supervisor Name:  Supervisor Phone:  

Duties and Responsibilities:

Reason for leaving:  

Employment Dates:    from  to

Employer Name:       

Employer Address:  

Starting Salary:      Ending Salary:      Job Title:

Supervisor Name:  Supervisor Phone:  

Duties and Responsibilities:

Reason for leaving:  

General:

May we contact your current employer?    yes    no

If hired, will you be able to work overtime?    yes    no

Will you be able to perform the essential job functions for the position you are applying for with or without reasonable accommodations?    yes    no

Have you ever been convicted of a crime, excluding misdemeanors and summary offenses, which has not been annulled, expunged, or sealed by the court?    yes    no

(a yes response does not automatically disqualify your application)

The above information is true and correct.  I understand that, in the event of my employment by the company, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery.

I authorize the Company to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position.  I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my  former employer harmless from any claim made on the basis that such information about me was provided  or that any employment decision was made on the basis of such information.  I further authorize the Company to obtain any credit and consumer check.

I understand that nothing in this employment application, the granting of an interview or my subsequent employment with the Company is intended to create an employment contract between myself and the company under which my employment could be terminated only for cause.  On the contrary, I understand and agree that, if hired, any employment  will be terminable at will and may be terminated by me or the Company at any time, and for any reason.  I understand that no person has any authority to enter into any agreement contrary to the foregoing.  If employed, I will be required to provide original documents which verify my identity and right to work in the United States under the immigration Reform and Control Act (IRCA) of 1986.  The document(s) provided will be used for completion of forms I-9.

I hereby acknowledge that I have read and agree to the above statements.

Select if you AGREE or DISAGREE with the above statements:    AGREE    DISAGREE