Our Company is an equal opportunity employer and will consider all applicants for all positions equally without regard to their race, sex, age, color, religion, national origin, veteran status or any disability as provided in the Americans With Disabilities Act.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered.

PERSONAL INFORMATION:

Date ___/____/____

Full Name ________________________________________________________________

Home Phone (___) ________________________
Cell Phone (___) _________________________

Present Address __________________________________________________________________________
(NO., Street, City, State, ZIP)

Social Security No. _______________________ Are you over 21? Yes____ No____

Are you a citizen of the U.S. or do you have the legal right to be employed in the United States? Yes____ No____

Have you ever been convicted of any crime (excluding minor traffic violations) including driving while under the influence of alcohol or drugs? Yes____ No____

If yes, state the offense, location, and date and disposition ________________________
__________________________________________________________________________
Note: A conviction will not necessarily disqualify you from employment.

Do you have the ability, with or without reasonable accommodations, to work overtime if overtime is required by the job for which you are applying? Yes____ No____

EMPLOYMENT DESIRED:

Are you seeking full-time___ part-time___ temporary___ or summer___ employment?
Position applied for ____________________________ Salary Desired _______________
Date Available to start __________________________

Have you ever applied or worked for our company before?
Yes____ No____

How did you learn of our company and the position? ____________________________

Are you now, or do you expect to be, working in any other business or job?
Yes____ No____
Are there any days or hours you would be unable or unwilling to work?
Yes____ No____
If yes, please specify those days or hours you would be unable or unwilling to work
_____________________________________________________________________
EDUCATION:

High School: _______________________________Address:___________________
# of Years Completed:____________________ Did you graduate? Yes____ No____

College/University: __________________________Address: ___________________
# of Years Completed:____________________ Did you graduate? Yes____ No____

Trade School: ______________________________ Address: __________________
# of Years Completed: ____________________Did you graduate? Yes____ No____

List or describe any other School, Specialized Training, or activities involved in during high school and college
_____________________________________________________________________

MILATARY:

Have you ever served in the military? Yes____ No____

Service Branch ____________________ Date Entered ________________________

Date Separated ___________________________Final Rank ____________________

CAPABILITY / RELIABILITY:

Would you be willing and able to perform all of the tasks required by the job you are applying for? Yes____ No____
If not, explain which tasks ________________________________________________

Have you filed any type of fraudulent claim against any of your present or past employers? Yes____ No____
If yes, please explain ___________________________________________________

Have you ever been disciplined for violating company safety rules or regulations?
Yes____ No____
If yes, please explain ___________________________________________________

How many days of work (or school) have you missed in the last two years?
____________________________________________________________________

How many times have you been late for work (or school) in the last two years?
___________________________________________________________________

Would you be willing and able to report to work on time, every day, on a regular and consistent basis? Yes____ No____

If no, please explain __________________________________________________

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.

Dates of Employment: From___/___/___ To ___/___/___
Position(s) Held: ________________________________
Firm: _________________________________ Address:____________________
Phone ( )____________ Supervisor: ______________ Title _________________
Responsibilities:
__________________________________________________________________
Starting Salary and Title: ______________ Ending Salary and Title: __________
Reason for Leaving: ________________________________________________

Dates of Employment: From___/___/___ To ___/___/___
Position(s) Held: ________________________________
Firm: _________________________________ Address:____________________
Phone ( )____________ Supervisor: ______________ Title _________________
Responsibilities:
__________________________________________________________________
Starting Salary and Title: ______________ Ending Salary and Title: __________
Reason for Leaving: ________________________________________________

Dates of Employment: From___/___/___ To ___/___/___
Position(s) Held: ________________________________
Firm: _________________________________ Address:____________________
Phone ( )____________ Supervisor: ______________ Title _________________
Responsibilities:
__________________________________________________________________
Starting Salary and Title: ______________ Ending Salary and Title: __________
Reason for Leaving: ________________________________________________

Are you presently employed? Yes____ No____
If yes may we contact your present employer? Yes____ No____

Have you ever been fired, or asked to resign, from a job? Yes____ No____
If yes, please explain ____________________________________________
Have you ever been disciplined or received verbal or written warnings for absenteeism or tardiness? Yes____ No____

REFERENCES:
Give three references, not including relatives or former employers.
Name_________________________ Address________________________
Phone________________________ Occupation______________________

Name_________________________ Address________________________
Phone________________________ Occupation______________________

Name_________________________ Address________________________
Phone________________________ Occupation______________________

AFFIDAVIT:
I certify that my answers to the foregoing are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application form or during the interviews may be grounds for my immediate discharge.
I hereby authorize the Company to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. In addition, I hereby waive my rights to bring any cause of action against these individuals for defamation, invasion of privacy or any other reason because of their statements.
I agree that if employed, I will abide by all the rules and regulations of the Company. I understand that the taking of drugs and alcohol tests, when given pursuant to Company policy, are a condition of continued employment and refusal to take such tests when asked will be grounds for my immediate termination. I also understand that my employment is “at-will” and may be terminated by myself or by the company at any time for any reason at all, with or without prior notice.

Signature________________________ Date ____/____/___