Name

Email

Present Address: Street

Present Address: City

Present Address: State

Present Address: Zip

Home Phone

Business Phone

Other Addresses during the last five (5) years:

Street

City

State

Zip

Dates lived at this address

Street

City

State

Zip

Dates lived at this address

Are you over the age of 18?
Yes No

If yes, can you verify your birthdate?
Yes No

Are you either a U.S. citizen or an alien authorized to work in the U.S.?
Yes No

If yes, can you verify your identity and eligibility to work in the U.S.?
Yes No

Position applied for:

Date you can start:

PRESENT AND PAST EMPLOYMENT, BEGINNING WITH YOUR MOST RECENT

Name and address of company and type of business

From: (Month and Year)

To: (Month and Year)

Describe in detail the work you did.

Last salary

Reason for leaving

Name and title of supervisor

Name and address of company and type of business

From: (Month and Year)

To: (Month and Year)

Describe in detail the work you did.

Last salary

Reason for leaving

Name and title of supervisor

Name and address of company and type of business

From: (Month and Year)

To: (Month and Year)

Describe in detail the work you did.

Last salary

Reason for leaving

Name and title of supervisor

Name and address of company and type of business

From: (Month and Year)

To: (Month and Year)

Describe in detail the work you did.

Last salary

Reason for leaving

Name and title of supervisor

Have you ever been discharged or asked to resign?
Yes No

If yes, please explain:

Have you ever been convicted of any crime under civilian or military law, other than minor traffic violations?
Yes No

If yes, list the date and nature of each offense (although such conviction does not necessarily exclude applicant from all employment categories):

EDUCATION RECORD

High School

Courses of Study

Number of years completed

Did you graduate?
Yes No

Type of diploma or degree

College

Courses of Study

Number of years completed

Did you graduate?
Yes No

Type of diploma or degree

Other (Specify)

Courses of Study

Number of years completed

Did you graduate?
Yes No

Type of diploma or degree

Please state the names of three professional references who may be contacted.

Name

Address

Phone

Years Known

Name

Address

Phone

Years Known

Name

Address

Phone

Years Known

In case of emergency notify:

Name

Relationship

Phone

Is there any reason why you cannot perform the essential functions of the job for which you have applied?
Yes No

If yes, explain and describe any accommodation required. (NOTE: We maintain a policy of reasonably accommodating handicapped or disabled employees, as required by law.)

Are you a veteran of U.S. military services?
Yes No

If yes, state branch, dates of service and duties:

Do you have a reserve commitment?
Yes No

If yes, please provide an approximate schedule. (Information shall not be utilized for any purpose other than scheduling.)

Please list other experiences, activities, skills, achievements, or qualifications which you believe will aid in reviewing your application. (You need not include the name of any organization, the name or character of which indicates the race, color, religion, sex, national origin, handicap, or ancestry of its members.)Please email, fax, or mail additional information or resume if necessary.

Additional comments

TO THE APPLICANT: PLEASE READ THE FOLLOWING CAREFULLY BEFORE SUBMITTING.

I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSE STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY EDUCATION, PREVIOUS EMPLOYMENT, WORK HABITS, CHARACTER, AND/OR SKILLS, ARREST AND CONVICTION RECORD, AND ANY OTHER PERTINENT INFORMATION THEY MAY HAVE CONCERNING ME. I HEREBY AUTHORIZE YOU TO CONTACT ANY AND ALL FORMER EMPLOYERS, SCHOOLS, RERFERENCES, AND PERSONS NAMED IN THIS APPLICATION OR ANY LAW ENFORCEMENT AGENDY, AND I HEREBY RELEASE SAID PARTIES FROM ANY AND ALL LIABILITY WHATSOEVER FOR PROVIDING YOU WITH SUCH INFORMATION. A COPY OF THIS APPLICATION ON WHICH MY SIGNATURE APPEARS SHALL BE EFFECTIVE FOR THE RELEASE OF THE INFORMATION REQUESTED HEREIN.

I AGREE NOT TO DISCLOSE OR PERMIT DISCLOSURE OF ANY FINANCIAL OR PROPRIETARY INFORMATION OR TRADE SECRETS OF THE EMPLOYER THAT MAY BE LEARNED DURING THE COURSE OF MY EMPLOYMENT.

I UNDERSTAND THAT MY EMPLOYMENT IS CONTINGENT UPON COMPLETING AND PASSING A CRIMINAL RECORD CHECK BY THE BUREAU OF CRIMINAL IDENTIFICATION AND INVESTIGATION (BCII) AND BY THE FEDERAL BUREAU OF INVESTIGATION (FBI) AND UPON PASSING THE AGENCY'S DRUG TEST. I ALSO UNDERSTAND THAT REASONABLE ACCOMMODATION TO ANY HANDICAP OR DISABILITY ACCORDING TO LAW, WILL BE TAKEN INTO CONSIDERATION.

IF EMPLOYED, I HEREBY AUTHORIZE DEDUCTIONS FROM WAGES DUE ME FOR ANY AMOUNT I OWE TO THE EMPLOYER OR FOR CHARGES I HAVE INCURRED, INCLUDING BUT NOT LIMITED TO: TELEPHONE CALLS, DAMAGES TO PROPERTY OR EQUIPMENT, FAILURE TO FOLLOW POLICIES WHICH RESULT IN CASH OR INVENTORY SHORTAGES.

I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS AT WILL AND FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE. NO ONE HAS THE AUTHORITY TO CHANGE THE TERMS OF THIS EMPLOYMENT RELATIONSHIP.

I ACCEPT