Job Application

AN EQUAL OPPORTUNITY EMPLOYER We do not discriminate on the basis of race, religion, national origin, color, sex, age, disability or veteran status. It is our intention that all applicants be given equal opportunity and that selection decisions are based on job related performance factors. The fact that this application has been provided to you does not necessarily mean there are positions available and does not in any way obligate the Company to offer you employment. INSTRUCTIONS—Each question/part must be fully and accurately completed. Further consideration may not be given until all questions/parts have been completed. Do not provide any information unless the application specifically requests it.

You may also download a PDF copy of the form to complete.

Fields marked with an asterisk (*) must be filled out before submitting.

Last Name: *

First Name: *

Street Address: *

City: *

State: *

Zip Code: *

Telephone: *

Cell Phone: *

Email: *

Are you over 18 years of age? *

Are you a citizen of the United States? *

If No, are you in the U.S. under a Visa? *

Have you completed an application with this company before? *

If Yes, when?

Have you been employed with this Company before? *

If Yes, when?

Is there any additional information concerning a change of your name or use of another name which would help us check your work record? *

If Yes, when?

United States Military Record

Were you in the Armed Services? *

If Yes, what branch?

If Yes, please detail what job experience you gained there:

Education

High School

High School Address (City, State)

Did you graduate High School?

College:

Location:

College Major:

Degree:

Did you graduate College?

Training/Skills

Please list any additional education and/or vocational technical training you have had:

Applicable Skills

Please include years of experience for any checked above:

Have you been convicted of a crime or pleaded nolo contendere (no contest) to a criminal offense (other than traffic violation) in the past 10 years? (Note: A “Yes” response does not automatically disqualify an applicant from employment.)

If Yes, complete the following and list all the instances even if adjudication was withheld: (Name at time of conviction or plea, date, Charge, Law Agency, Disposition)

Employment Record

Employer

Name:

Address:

City:

State:

Zip Code:

Phone Number:

Immediate Supervisor:

Supervisor Phone Number:

Dates you were employed:

Reason for leaving or looking to leave if still employed?

List all jobs you performed for this Company and the approximate length of time you worked each job:

Do we have permission to contact this Company?

Employer

Name:

Address:

City:

State:

Zip Code:

Phone Number:

Immediate Supervisor:

Supervisor Phone Number:

Dates you were employed:

Reason for leaving or looking to leave if still employed?

List all jobs you performed for this Company and the approximate length of time you worked each job:

Do we have permission to contact this Company?

Employer

Name:

Address:

City:

State:

Zip Code:

Phone Number:

Immediate Supervisor:

Supervisor Phone Number:

Dates you were employed:

Reason for leaving or looking to leave if still employed?

List all jobs you performed for this Company and the approximate length of time you worked each job:

Do we have permission to contact this Company?

References

By listing these 3 references; I verify that I know them either personally or professionally; and they may be contacted in regards to past/future employment or character checks. PLEASE: DO NOT LIST FAMILY MEMBERS.

Name: *

Relationship: *

Phone Number: *

Name: *

Relationship: *

Phone Number: *

Name: *

Relationship: *

Phone Number: *

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND PUT YOUR INITIALS BY EACH STATEMENT ON THE LINE PROVIDED.

I understand that either misrepresentations or omissions of facts called for on this application are causes for rejection of this application; or for subsequent dismissal from employment. (Your initials) *

I understand that at the time of employment, I must submit to and pass a pre – employment physical, and drug screening. Failure to pass may disqualify me from employment. (Your initials) *

If I am employed, I agree to comply with and be bound by the safety and work rules and other rules, regulations, and policies of the Company. (Your initials) *

I understand and accept that I must successfully complete the Company’s probationary period if I am hired. (Your initials) *

I understand that in the event my application for employment is accepted, the effective date of acceptance and of my employment shall be the time I actually begin work. (Your initials) *

I acknowledge and represent that I am not bound by any agreement or covenant of any kind that limits or restricts me from competing with any former employer, disclosing any confidential information or trade secrets, or contacting any former co – workers or customers with whom I have dealt. (Your initials) *

If hired; I understand that I am free to resign at any time, with or without cause and with or without prior notice; and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. (Your initials) *

I have read and understand the contents of this application. (Your initials) *

Name *

Date *