APPLICATION

FOR EMPLOYMENT
We consider applicants for all positions without regard to race, color, religion,
creed, gender, national origin, age, disability, marital or veteran status, or any
other legally protected status.
(PLEASE PRINT)
Position(s) Applied For Date of Application

How Did You Learn About Us?

Advertisement Friend Inquiry
Employment Agency Relative Other__________________

Last Name First Name Middle Name

Address Number Street City State Zip Code

Telephone Number(s) Social Security Number

AM
Best time to contact you at home is: ____ : ______ PM

If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No

Have you ever filed an application with us before? If Yes, give date_____________ Yes No

Have you ever been employed with us before? If Yes, give date _______________ Yes No

Do any of your friends or relatives, other than spouse, work here? Yes No
If Yes, state name, relationship and location _________________________

Are you currently employed? Yes No

May we contact your present employer? Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigra Yes No
Proof of citizenship or immigration status will be required upon employment.

Date available for work ____/____/____ What is your desired salary ________________

Are you available to work: Full Time (Please indicate 1 2 3 shift)

Part Time(Please indicate Mornings Afternoon Evenings)
Temporar(Please indicate dates available ___/___ - ___/___)

Are you currently on "lay-off" status and subject to recall? Yes No

Can you travel if a job requires it? Yes No

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

 EDUCATION

Name and Address Years Diploma/

School
of School Course of Study Completed Degree
High School
Undergraduat
e College
Graduate/
Professional
Other
Specify
WORK EXPERIENCE
Start with your present or last job. Include any job-related military service assignments and volunteer
activities. You may exclude organizations which indicate race, color, religion, gender, national origin,
disabilities or other protected status. Dates Employed Work Performed
Employer
From To
Address
Hourly Rate/Salary
Telephone Number(s)
Starting Final
Starting/Present Job Title
Supervisor
Reason for Leaving May We Contact? Yes
Dates Employed Work Performed
Employer
From To
Address
Hourly Rate/Salary
Telephone Number(s)
Starting Final
Starting/Present Job Title
Supervisor
Reason for Leaving May We Contact? Yes
Dates Employed Work Performed
Employer
From To
Address
Hourly Rate/Salary
Telephone Number(s)
Starting Final
Starting/Present Job Title
Supervisor May We Contact? Yes
Reason for Leaving
Dates Employed Work Performed
Employer
From To
Address
Hourly Rate/Salary
Telephone Number(s)
Starting Final
Starting/Present Job Title
Supervisor May We Contact? Yes
Reason for Leaving
Comments: Include explanation of any gaps in employment.
Describe any specialized training, apprenticeship, skills and extra-curricular

NAME:_________________________________________POSITION______________________DATE:______/______/______
Describe any job-related training received in the United States military.

List professional, trade, business or civic activities and offices held.

You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other prot

ADDITIONAL INFORMATION
Other Qualifications Summarize special job-related skills and qualifications acquired from employment or other .experience

SPECIALIZED SKILLS (Skills/Equipment Operated)

Production/Mobile
____ Terminal ____ Spreadsheet Machinery (list) Other (list)
____ PC/MAC ____ Word Processing
____ Typewrite ____ Shorthand
WPM____ WPM____

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 review of the activities involved in s
occupation has been given. ____YES ____NO

PERSONAL/PROFESSIONAL REFERENCES Do not include family members or past supervisors.

Name Phone Number Best Time to CallOccupation
APPLICANT'S STATEMENT
I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary

This application for employment shall be considered active for a period of time not to exceed 45 days. Any a
employment beyond this time period should inquire as to whether or not applications are being accepted at t

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relati
"at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee
cause. It is further understood that this "at will" employment relationship may not be changed by any written docu
change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information give in my application or interv
understand, also, that I am required to abide by all rules and regulations of the employer.

Signature of Applicant Date