Application for Employment

We appreciate your interest and your time in exploring our employment opportunities. We are an equal opportunity employer and will not unlawfully discriminate because of religion, national origin, color, gender, sexual orientation, age, 40 and over, disability, genetic information or any other status protected by applicable law or regulation. It is our intention that all qualified applicants are given equal opportunity and that selection decisions be based on jobrelated factors. Those applicants requiring reasonable accommodation to the application and/or interview process should notify are presentative of the organization. Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. Use an additional blank paper if you do not have enough room on this form. Please print, except for signature on the last page of application. In reading and answering the following questions, be aware that none of these questions are intended to imply illegal preferences of discrimination based upon non-job-related information.

PLEASE PRINT

Last Name: _________________ First Name: __________________ Middle initial: ____ Date:____________

Home Telephone: ______________ Alternative Telephone: ________________

Present Street Address: ________________________________ City: _____________ State: ___ Zip: __________

Email Address: _____________________________________

Have you ever been employed under any other name? □Yes □No

If Yes, please identify those names: ______________________________

Which position are you applying for? ______________________________

Are you seeking: □Full-time □Part-time

When are you available for employment? _____________ Salary desired: ________

Are you 18 years of age or older? □Yes □No

If hired, can you furnish proof that you are eligible to work in the United States? □Yes □No

Have you been convicted of a crime that has not been dismissed, annulled, expunged or sealed by court? This includes, but is not limited to petty offenses, misdemeanors, felonies, and DUI’s?

□Yes □No

Please note: A conviction will not necessarily deny employment, but failure to disclose a conviction will make you ineligible for employment.

If yes, please explain:___________________________________________________________________________

Education:

Type of School	Name/Location	Course of Study	Graduate	Degree or Certification
High School			□Yes □No
College			□Yes □No
Graduate			□Yes □No
Business/Technical			□Yes □No

Have you ever worked or attended school under any other names? □Yes □No

If yes, give names:______________________________________________________________________________

Please list all relevant professional licenses and certifications:

Other Skills and Qualifications

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

Referral Source: How did you learn about this position?

o Advertisement (Newspaper, Professional Publication etc.: _______________________________________ o Job Board: _____________________________________________________________________________ o School/College: _________________________________________________________________________ o Employee: _____________________________________________________________________________ o Other: _________________________________________________________________________________

Work History

PLEASE COMPLETE THIS SECTION, EVEN IF THIS INFORMATION IS ON YOUR RESUME. list your last three employers, in consecutive order, with present or most recent employer

listed first. Account for all periods of time, including military service and any periods of unemployment. If self-employed, give firm name and business references. Please include month and year for all dates of employment.

1. Name of Employer: _____________ Dates of Employment: From: ______ To: _________

Name of Last Supervisor: _ Hourly Pay: ______ Monthly: ________

Address/Telephone Number: _______________________________________________________

Your Position:____________________________________________________________________

Your Responsibilities

(If comprehensive resume is attached, note "See Attached Resume"):

________________________________________________________________________________

Reason for Leaving:__________________________________________________________________

Can we contact your current employer: ___ Name of Contact: __________________

2. Name of Employer: _____________ Dates of Employment: From: ______ To: _________

Name of Last Supervisor: _ Hourly Pay: ______ Monthly: ________

Address/Telephone Number: _______________________________________________________

Your Position:____________________________________________________________________

Your Responsibilities

(If comprehensive resume is attached, note "See Attached Resume"):

________________________________________________________________________________

Reason for Leaving:__________________________________________________________________

Can we contact your current employer: ___ Name of Contact: __________________

3. Name of Employer: _____________ Dates of Employment: From: ______ To: _________

Name of Last Supervisor: _ Hourly Pay: ______ Monthly: ________

Address/Telephone Number: _______________________________________________________

Your Position:____________________________________________________________________

Your Responsibilities

(If comprehensive resume is attached, note "See Attached Resume"):

________________________________________________________________________________

Reason for Leaving:__________________________________________________________________

Can we contact your current employer: ___ Name of Contact: __________________

References

Please provide three professional references that are willing to speak with us. Two of these references must be individuals to whom you reported directly.

Name

Company and Work Relationship

Email Address

Telephone Number

Please read each statement carefully before signing

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

I authorize verification of the accuracy of the information contained in this application from all previous employer, educational institutions, and references. I also herby release from liability the potential employer and its representatives for seeking, gathering and using such information to make employment decisions and all other persons or organization for providing such information.

I understand I may be required to successfully pass a drug screening examination. I herby consent to a pre-and/or post- employment drug screen as a condition of employment, if required.

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time may result in immediate termination of employment.

I understand that this application, verbal statement 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 designee 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 designee 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, with or without cause and with or without notice.

Signature: ____________________________________________ Date: ________________________