POSITION(S) APPLIED FOR:

Date Available to Start Work:

PERSONAL DATA

EMPLOYMENT HISTORY
Please list the most recent employer first.
Can we contact your most recent employer?

EDUCATIONAL DATA

REFERENCES List three individuals:

Name Address City, State, Zip Phone Occupation

General Information

Have you ever applied for a job with this company in the past? Yes No

If yes, please give the date of application and the position for which you applied. State your name at that time, if different from present name.

Have you ever been employed by this company in the past? Yes No
If yes, please give the dates of employment, position(s) held and state your name while employed, if different from present name.

Do you have any commitments to another employer that might affect your employment with our company? Yes No
If yes, please write explanation at the bottom of this page:

If hired, can you furnish proof that you are 18 years of ages, or if under 18, do you have a permit to work? Yes No
If no, please write explanation on the bottom of this page:

If hired, can you furnish proof that you are eligible to work in the United States? Yes No
If no, please write explanation on the bottom of this page:

Are you capable of satisfactorily performing the job(s) for which you are applying? Yes No
If no, please write explanation on the bottom of this page:

Do you have any experience from your military service that would be relevant to the job(s) for which you are applying? Yes No
If yes, please write explanation on the bottom of this page:

Do you have any language abilities, such as reading or speaking a foreign language, that might help you perform the job(s) for which you are applying?
Yes No
If yes, please write explanation on the bottom of this page:

Have you been convicted of a felony or released from prison in the past 10 years? Note: A yes answer does not automatically disqualify you from employment since the nature of the offense, date and type of job for which you are applying will be considered. Yes No
If yes, please write explanation on the bottom of this page:

Are you charged with an unresolved criminal charge? Note: A yes answer will not automatically disqualify you from employment. Yes No
If yes, please write explanation on the bottom of this page:

Are you willing and physically able to travel to out-of-town locations, including overnight trips? Yes No
If no, please write explanation on the bottom of this page:

Do you have a valid driver’s license? Yes No

During the past seven years, have you ever been denied a driver’s license, or convicted of a moving traffic offense, including, but not limited to, driving while intoxicated orreckless driving? Yes No
If yes, please write explanation on the bottom of this page:

Do you have all the licenses and professional certification listed in the job announcement, job advertisement, or job description, or that are necessary to perform the job(s) forwhich you are applying? Yes No
If no, please write explanation on the bottom of this page:

By my signature and initials placed below, I promise that the information provided in this employment application and accompanying resume, if any, is true and complete. I understand that any false information or significant omissions may disqualify me from further consideration for employment and my be justification for my dismissal from employment, if discovered at a later date. I agree to immediately notify the company if I should be convicted of a felony or any crime involving dishonesty or a breach of trust while my job application is pending or during my period of employment, if hired.

Initials

I authorize the investigation of all statements contained in this application and accompanying resume, if any. I also authorize the company to contact my present employer unless otherwise noted in this application form, past employers and listed references. I understand that the company may request an investigative consumer report from a consumer reporting agency that includes information as to my character, general reputation, personal characteristics and mode of living. I understand that the investigative consumer report may involve personal interviews with neighbors, friends, relatives, former employers, schools and others. I also understand that under the Federal Fair Credit Reporting Act I have the right to make a written request to the company, 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.

Initials

I authorize any person, school, current employer (except as previously noted), past employer(s), and organizations named in this application form and accompanying resume, if any, to provide the company with relevant information and opinion that may be useful to the company in making a hiring decision, and I release such persons and organizations from any legal liability in making such statements.

Initials

I give permission for a complete physical examination, including a drug screening exam and X-rays, and I consent to the release to the company of any and all medical information, as may be deemed necessary by the company in judging my capability to do the work for which I am applying.

Initials

I understand that if my employment is terminated by the company for dishonesty, breach of trust or any criminal acts the authorities may be notified and I may be criminally prosecuted. I also understand that, If hired, I may not hold other employment, nor engage in sales, investments or other activities that create a conflict of interest with my position with this company.

Initials

I understand that this application does not, by itself, create a contract of employment. I understand and agree that, if hired, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD OF TIME, and may, regardless of the date of payment of my wages or salary, BE TERMINATED AT ANY TIME. I understand that NO PERSON IS AUTHORIZED TO CHANGE ANY OF THE TERMS MENTIONED IN THIS EMPLOYMENT FORM.

Initials

This application for employment will remain active for 45 days. After that time, applicants will be required to resubmit a completed application.

Initials

Extra:  (Use this box for anything extra you want to say...you could also cut and paste a resume into this
section as well if you please)

Date Completed on: