Employment Application Form

We consider applicants for all positions without regard to race, color, religion, creed, gender. national origin, age, sexual orientation, special disability, medical or veteran status in accordance with Federal law. In addition, we comply with applicable state and local laws prohibiting discrimination in employment in every jurisdiction in which we maintain facilities/ We are an "at-will" employer and retain the right to terminate at any time with or without reason or notice.

Last Name:

First Name:

Middle Name:

Address:

City:

State:

Zip:

How did you learn about us?

Advertisment

Friend

Walk-in

Employment Agency

Relative

Other

If other, please specify:

Referred By:

Are you over the age of 18?

Yes No

If not, state age:

Have you ever filed an application with us before?

Yes No

If yes, give the date:

Have you ever been employed with us before?

Yes No

If yes, give the date:

Are you currently employed?

Yes No

May we contact your present employer?

Yes No

Federal law requires that employers hire only individuals who are authorized to be lawfully employed in the United States. In accordance with such laws, all offers of employment are subject to verification of the applicant's identity and employment authorization, and it will be necessary for you to submit such documents as required by law to verify your identification and employment eligibility upon employment.

Are you authorized to work for all employer in the United States on a full-time basis, or only for your current employer?

All Current

On what date you would be able to work?

Are you able to work:

Full Time Part Time Temp PRN

Are you currently on "lay-off" status or subject to recall?

Yes No

Can you travel locally if a job requires it?

Yes No

Have you ever been convicted to a crime?

Yes No

If yes, state the nature of the offense, when, where, and disposition:

Employment Experience

Starting with your present or last job, include any job-related military service assignments and volunteer activities. You may exclude organizations that indicate race, religion, gender, national origin, sexual orientations, disabilities, or other protected status. Account for any gaps in your employment. All areas must be completed. Incomplete applications will stop the interview process. Do not write "See resume."

Add Information

Education / Training

High School:

Name and Address of School:

Course of Study:

Years Completed:

Diploma or Degree:

Undergraduate College:

Name and Address of School:

Course of Study:

Years Completed:

Diploma or Degree:

Graduate College:

Name and Address of School:

Course of Study:

Years Completed:

Diploma or Degree:

Others (Specify):

Add Information

Describe any specialized training, apprenticeship, or skills:

List any job-related licenses, certifications, registrations, you have received:

Add Information

Has your license in this state or any other ever been suspended, limited, or revoked?

Yes No

If yes, please explain circumstances:

Have you ever been subject to disciplinary action or place under investigation by a licensing policy?

Yes No

If yes, please explain circumstances and results:

List any professional trades, business, or civic activities and offices held, current or past: You may exclude memberships which would reveal, gender, race, religion, national origin, age, ancestry, disability, or any protected status:

Work Related Reference

Add Information

State any additional information you feel may be helpful to us in considering your application:

Note to Applicants: Do not answer this question unless you have been informed about the requirements of the job for which you are applying.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A description of the activities involved in such a job or occupation has been provided.

Yes No

Applicant Certification and Disclosure Agreement

Please read carefully and sign below

I understand and agree that:

The information I have provided on this application is true and complete to the best of my knowledge. Misrepresentations or omission of any facts in my application, resume, or any other materials, or during any interviews can be the justification of refusal of employment, or If employed, termination from the Company.
Any offer of employment I may receive from the Company is contingent upon my successful completion of the Company's pre-employment screening process, including the Company's receiving of references that it considers satisfactory, and my satisfactory completion of any post-offer medical examination, at any time, at the company's request. I hereby consent to have the results of any post-offer pre-employment, or post-employment medical exams I may be required to take, disclosed to the Company.
I understand that as a condition of employment, I will be required to undergo and successfully pass a screening for alcohol and/or drugs. I also understand and agree that, if employed, I may be required to submit to an alcohol or drug screening at any time at the discretion of the Company. I further consent to having the results of any such alcohol or drug screening I may be required to undergo disclosed to the Company.
In processing my application for employment, the Company may verify all the information provided by me or may procure or have prepared a report concerning my prior employment, military record, education, character, general reputation, personal characteristics, criminal record, and mode of living. I understand that upon written request of the Company, I will be informed whether an investigative consumer report was requested and given full information as to the nature and scope of the Investigation.
I authorize any request that all of my present and former employers and those individuals I have listed as personal references furnish information about my employment record, including a statement of the reason for the separation of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment, thereby releasing them. from any and all liability for damages arising from furnishing the requested information.
In consideration of employment, I agree to comply with the policies, rules, regulations, and procedures of the Company and understand that my employment and compensation can be terminated at will, with or without cause or notice, at any time, at the option of either the Company or myself. I further understand that no manager or representative of the Company, other than the Chief Executive Officer, President, or Human Resources Manager, has any authority to enter into any agreement with me for employment for any specified period of time or to make any agreement different from or contrary to the foregoing. I further understand that any such agreement, if made, shall not be enforceable unless it is in writing and signed by me and by one of the individuals designated above.

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

Background Investigation Consent

I, (Please put name below) hereby authorize (Please put name below) and/or its agents to make an Independent Investigation of my background, references, character, past employment, education, credit history, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the Information contained on my Application and/or obtaining other information which may be material to my qualifications For employment now, and, if applicable, during the tenure of my employment with the Company.

Please put name here:

I release (Please put name below), and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities claims or law suits in regards to the Information obtained Prom any and all of the above referenced sources used.

Please put name here:

Please Ilst all Residence Addresses for the past seven years. Use separate sheet if needed:

Present Residential Address:

City:

State:

Zip:

How long?

Former Address #1:

City:

State:

Zip:

How long?

Former Address #2:

City:

State:

Zip:

How long?

The following Is my true and complete legal name and all Information contained herein Is true and correct to the best of my knowledge:

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Applicant / Employee Name:

Date:

Social Security #:

Date of Birth:

Driver's License Number:

Your information will be encrypted.