Application for Employment

Equal access to programs, services and employment is available to all persons. Those applicants requiring a reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department. We are an equal opportunity employer.

Position Applied For

Application Date

Name: Last

First

Middle

Address: Street

City

State

Zip Code

Home Phone

Cellular/Other

Email address

Shift Preferred

Any

Expected Pay

Would you accept full-time work?

Yes No

Would you accept part-time work?

Yes No

On what date would you be available for work?

If necessary, best time to call you is

Contact at

Home

Cellular/Other

How were you referred to our Company?

Have you submitted an application here before?

Yes No

If yes, please give date(s) and position(s):

Have you ever been employed here?

Yes No

If yes, please give dates.

Is this application a request for reemployment following an extended military leave of absence from our Company? If yes, additional information may be requested.

Yes No

If you are under 18 years old, can you provide a work permit if required?

Yes No

Are you legally eligible for employment in the United States? (If yes, proof is required if hired.)

Yes No

Are you able to perform the “essential functions” of the job for which you are applying (with or without reasonable accommodation)? NOTE: This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage, to the extent permitted by law.

Yes

Need more information about the job’s “essential functions” to respond

Will you travel if required?

Yes No

Will you work overtime if required?

Yes No

If they have been explained to you, are you able to meet the attendance requirements of the position?

Yes No N/A

Have you ever been bonded?

Yes No

Please provide your driver's license number, if driving is required for this job.

State

Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our Company?

Yes No

If yes, please explain.

NOTE: Answering “yes” to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Have you ever pleaded “guilty” or “no contest” to, or been convicted of, a crime?

Yes No

If yes, please provide date(s) and details:

Employment Experience

Place a check by the employer(s) you DO NOT want us to contact. List your most recent employer first.

Add Employment Experience

Explain any gaps in your employment, other than those due to personal illness, injury or disability.

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

Yes No

If yes, please explain:

Education Background

High School

Location

Course of Study

Did you graduate?

Yes No

Degree or Diploma

College

Location

Course of Study

Did you graduate?

Yes No

Degree or Diploma

Graduate School

Location

Course of Study

Did you graduate?

Yes No

Degree or Diploma

Vocational Training/Other

Location

Course of Study

Did you graduate?

Yes No

Degree or Diploma

Continuing Education

Special Training or Skills

Languages, machine operation, etc., that would be of benefit in the job for which you are applying.

Social Security Number

SS#

The Company will make reasonable efforts to safeguard the privacy of this information and will use it only for employment purposes.

References

List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

Add Reference

Applicant Statement

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time.

If hired, I agree to conform to the Company’s rules and regulations, and I understand that these rules and/or the employee handbook do not form a contract of employment either express or implied, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice to the extent permitted by law, at any time, at either my or the Company’s option.

I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the Company. I understand that no Company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the forgoing.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, résumé or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using truthful and nondefamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

I also understand that, if | am hired, I will be required to provide proof of identity and legal authorization to work in the United States as required by federal immigration laws.

This Company does not tolerate unlawful discrimination or harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state or local law. No question on this application is used to limit or exclude an applicant from employment consideration on any basis prohibited by applicable federal, state or local law.

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

Applicant's Signature

Date

Your information will be encrypted.