INSTRUCTIONS: Fill out this form entirely. Put NA in boxes that you do not know the answer to, or the question does not pertain to you. An application with ANY boxes empty will be discarded automatically.

Contact Information

Date:
First Name: Middle Name: Last Name:
Street Address:
City: State: Zip Code:

Home Phone: Cell Phone:
Email Address:

Legal Questions

Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation.) Yes No

Do you have a current, active driver's license? Yes No

Is there any reason that could hinder you from being insured to drive a company vehicle? Yes No

Are you looking for full-time employment? Yes No
If no, what hours are you available?:

Have you been convicted of a felony within the last 7 years? (This will not necessarily affect your application.)
Yes No
If yes, please describe:


Employment Desired

Position applied for:
How did you hear of this opening?:
Have you ever applied for employment here? Yes No
When?:
Where?:
Have you ever been employed by this company? Yes No
When?:
Where?:
Are you presently employed? Yes No
May we contact your present employer? Yes No
Are you available for full-time work? Yes No
Are you available for part-time work? Yes No
Are you willing to travel? Yes No
Date you can start?:
Desired position?:
Desired starting salary?:
Please list applicable skills?:


Education

Name of High School:
Year: Major: Degree:

Name of Community College:
Year: Major: Degree:

Name of College:
Year: Major: Degree:

Name of Post College:
Year: Major: Degree:

Other Training:
Year: Major: Degree:

In addition to your work history, are there other skills, qualifications, or experience that we should consider?:


Employment History

(List last three employers, starting with the most recent)

Company Name:
Address:
Date Started: Starting Wage: Starting Position:
Date Ended: Ending Wage: Ending Position:
Name of Supervisor:
May we contact? Yes No
Responsibilities:

Reason for leaving:

Company Name:
Address:
Date Started: Starting Wage: Starting Position:
Date Ended: Ending Wage: Ending Position:
Name of Supervisor:
May we contact? Yes No
Responsibilities:

Reason for leaving:

Company Name:
Address:
Date Started: Starting Wage: Starting Position:
Date Ended: Ending Wage: Ending Position:
Name of Supervisor:
May we contact? Yes No
Responsibilities:

Reason for leaving:

References

List three personal references, not related to you, who have known you for more than one year.
Name: Phone: Years Known:
Address:

Name: Phone: Years Known:
Address:

Name: Phone: Years Known:
Address:

Emergency Contact Information

In case of emergency, please notify:
Name: Phone:
Address:

Name: Phone:
Address:

Please Read Before Submitting Application

I certify that all information provided by me on this application is true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this application.

I authorize my previous employers, schools, or persons listed as references to give any information regarding employment or educational record. I agree that this company and my previous employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or employment is terminated because of false statements, omissions, or answers made by myself on this application. In the event of any employment with this company, I will comply with all rules and regulations as set by the company in any communication distributed to the employees.

In compliance with the Immigration Reform and Control Act of 1986, I understand that I am required to provide approved documentation to the company that verifies my right to work in the United States on the first day of employment. I have received from the company a list of the approved documents that are required.

I understand that employment at this company is “at will,” which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I hereby acknowledge that I have read and understand the above statements.

Legal Name of Applicant: I Give My Consent To Above Statements