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An Equal Opportunity Employer

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

Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information.

Are you seeking: Full timePart timeTemporary employment

Job applied for

Desired wage

Today's date

When can you start work?

GENERAL

Last name

First name

Middle name

Telephone number

Address

City

State

Zip code

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

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

Are you physically able to perform the job you are applying for? (i.e. lifting at least 80lbs, kneeling, standing, sitting, bending, lifting above the shoulders) YesNo

Emergency contact

Telephone number

Have you ever applied here before? YesNo

If yes, when?

Were you ever employed here YesNo

If yes, when?

Have you ever been convicted of any law violation? (Include any plea of “guilty” or “no contest.” Exclude minor traffic violations.) (A conviction will not necessarily disqualify an applicant for employment.) YesNo

If yes, give details

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

If yes, give details

EDUCATION

Number of diplomas

Years

Degrees

School 1

Name

Address

Completed certificate


School 2

Name

Address

Completed certificate


School 3

Name

Address

Completed certificate

Choose one: High schoolGED

Choose one: CollegeUniversity

Subjects studied

Choose one: VocationalTechical

Subjects studied

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?

For Driving Jobs Only: Do you have a valid driver’s license? YesNo

Driver's license number

Class of license

State licensed in

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

If yes, give details

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, genetic information or other protected status.)

WORK 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. Note: A job offer may be contingent upon acceptable references from current and former employers.

Employer 1

Company name

Address

Phone

Dates employed

Supervisor name

Reason for leaving


Employer 2

Company name

Address

Phone

Dates employed

Supervisor name

Reason for leaving


Employer 3

Company name

Address

Phone

Dates employed

Supervisor name

Reason for leaving

Have you worked or attended school under any other names? YesNo

If yes, give names

Are you presently employed? YesNo

If yes, whom do you suggest we contact?

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

If yes, please explain

Give three references, not relatives or former employers.

Reference 1

Name

Address

Phone


Reference 2

Name

Address

Phone


Reference 3

Name

Address

Phone

AFFIDAVIT, CONSENT AND RELEASE

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 initials consent to these statements. YesNo

Name or e-signature

Date

This application for employment will remain active for a limited time.

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