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Employment Application

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THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT. It is intended to evaluate suitability for employment. It is the policy of the company to provide equal employment to all qualified persons without discrimination on the basis of sex, race, color, religion, age, marital status, national origin, citizenship, disability, veteran status, or any other protected status under applicable federal, state or local law. If a job offer is made, employment will be contingent upon a successful completion of a medical examination, drug screen and background check. Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Referral Select Referral Method:

Job Posting Select Posting to Apply for:

Personal Information

First Name

Middle Name

Last Name

Home Phone

Work Phone

Cell Phone

Email Address

Addresses

	Street	City	State	Zip Code	Since (Mo/Yr)	To (Mo/Yr)
Current Address
Prior Address
Prior Address:

Education

	School Attended	City	State	Diploma	Degree/Cert.	Area of Study
High School				No Yes	GED
Undergrad School				No Yes
Grad School				No Yes
Other School				No Yes

Employment Information

Position Applied For

Date You Can Start

(yyyy-mm-dd)

Desired Salary: $

Do You Prefer

Can you work

Weekends
Evenings

Available:

M Tu W Th F Sa Su

Are you available for shift work?

No Yes

Not Available

Please answer all of the following questions.

1.	Are you at least 18 years of age and legally eligible to work for our company in the United States?	No Yes
	If you are under 18 years of age, can you provide required proof of your eligibility to work?	No Yes

Have you worked for this business before?

No Yes

If yes, please provide dates and locations.

Have you received a description of the job or been made aware of the essential functions of the job for which you are applying?

No Yes

Do you understand the job requirements?

No Yes

If no, please explain.

Are you on layoff and subject to recall?

No Yes

Are you currently bound by a noncompetition, confidentiality or trade secret agreement?

No Yes

If yes, please explain...

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

No Yes

If yes, please explain...

Have you ever been convicted of or pled guilty to a felony or crime other than a minor traffic citation?

No Yes

If yes, please explain...

Do any of your friends or relatives, other than spouse, work here?

No Yes

If yes, state name and relationship...

Employment History

Are you currently employed?

No Yes

May we contact your present employer?

No Yes

	Most Recent Employer	Prior Employer	Prior Employer	Prior Employer
Employer
City
State
Zip Code
Phone
Position Held
From (m/yyyy)
To (m/yyyy)
Pay upon leaving
Supervisor
Duties
Reason For Leaving

Job-related Skills

Please answer the following questions if the position you are applying for requires driving a motor vehicle

Do you have a valid driver's license?

No Yes

	If yes, Driver's License Number
	Date of Issue

Have you been convicted of or pled guilty to any traffic-related offense within the past five years?

No Yes

If yes, please explain...

Have you had your driver's license suspended or revoked or had your driving privileges modified by a court of law?

No Yes

If yes, please explain...

Please list all states from which you hold or held a driver's license

5.	Please use this space to list any special skills you may have that relate to the position applied for

6.	Please list any professional licenses, designations, certifications, etc. that may relate to the position applied for. Include date granted, name of organization, and any other relevant information.

References

	Reference (1)	Reference (2)	Reference (3)	Reference (4)
Name
Address
Telephone
Relationship
Years Acquainted

Resume (Text Version)

	Copy and Paste a text version of your resume here.

Upload File

	Attach a file to your application submission (Permitted File Types: doc,docx,pdf,txt - Max file size: 1045876 bytes)

Applicant Certification Agreement

1.	The company and other persons or employers are released from all liability brought forth by any investigation resulting from my submission of this electronic application and the data contained here in.
2.	The information in this application is true and complete to the best of my knowledge. Any falsification, misrepresentation, or omission on this application can be cause for denial or termination of employment.
3.	If hired, my employment is voluntary, meaning that either party can employment at any time for any reason. Upon acceptance of employment if a position is offered, I agree to abide by all existing and future company rules and regulations. The company reserves the right to change any working agreement as deemed necessary.
4.	Any employment offer is contingent open my providing proof of identity and eligibility to work the country of employ.
5.	I have read and reviewed the information provided in this application and the above statements. By signing this application for employment I certify that I understand all parts of it and have answered all questions completely and fully.
6.	I understand that by typing my name in the signature box below and submitting this application electronically, this becomes a legal and binding contract.

Security Code

	Type Name in Signature Box:	Date: 2023-12-08 05:14:24