Last Name *

First Name *

Middle

Current (mailing) Address (Street, City, State and Zip Code) *

Permanent Address (Street, City, State and Zip Code) *

Same as aboveNo

Day Phone * (Include Area Code)

Evening Phone (Include Area Code)

Cell Phone (Include Area Code)

E-mail *

Are You 18 Or Over? *

YesNo

Are You Legally Authorized To Work In The U.S.? * Proof Will Be Required

YesNo

Job Applied For

For What Type Of Job Are You Applying? *

Interested in: *

Full TimePart TimeTemporarySummer

Shift Preferred: *

1st Shift2nd ShiftEither

List Up To 3.

Hourly Wage Desired *

Date Available

Have You Ever Been Convicted, Pled Guilty Or No Contest To A Misdemeanor Or Felony? *

(Omit Minor Parking Violations)
YesNo
(Provide Dates and Explanation)

A conviction will not necessarily disqualify you from employment. Applicants with a conviction record who are denied employment may request a written explanation concerning the denial.

Have You Worked For This Company Before? *

YesNo

Date(s) and Reason(s) for Leaving

Work History

Include Volunteer, Apprenticeships, Self-Employment And Military Experience. (Start with most
recent employer and cover the past 7 years).

Are You Presently Employed? *

YesNo

May We Contact Your Present Employer? *

YesNoN/A

Current or most recent Employer *

Reason for Leaving *

Address (Street, City, State and Zip Code) *

Manager's Name *

Phone Number *

Dates Employed *

Type of Business

Job Title *

Hrs/Wk

Hourly Wage *

1st Previous Employer

Reason for Leaving

Address (Street, City, State and Zip Code)

Manager's Name

Phone Number

Dates Employed

Type of Business

Job Title

Hrs/Wk

Hourly Wage

2nd Previous Employer

Reason for Leaving

Address (Street, City, State and Zip Code)

Manager's Name

Phone Number

Dates Employed

Type of Business

Job Title

Hrs/Wk

Hourly Wage

3rd Previous Employer

Reason for Leaving

Address (Street, City, State and Zip Code)

Manager's Name

Phone Number

Dates Employed

Type of Business

Job Title

Hrs/Wk

Hourly Wage

If you have been unemployed for a period of 3 or more consecutive months within the past 5 years, please provide the dates of unemployment and an explanation below.

As an equal opportunity employer, our Company does not discriminate in hiring or employment on the basis of race, color, religion, creed, national origin, citizenship status, sex, age, marital status, disability, or veteran status. No question on the application is intended to secure information about these subjects.

Education and Licenses

High School Name *

City and State *

High School Diploma or GED? *

YesNo

If No, Select Highest Yr. Completed

Year:

89101112

Date Attended:

Advanced Education (School name) *

City and State *

Major:

Date Attended:

Did you graduate?:

YesNo

If so, what type of degree?:

List Any Licenses You Have Which Would Be Useful In Evaluating Your Qualifications For The Position You Are Seeking:

Answer the Following Questions Only If You Will Be Using a Motor Vehicle For Company Business.

Have You Had Any Motor Vehicle Accidents Within The Past 3 Years?

YesNo

Year:

Please Explain:

Have You Been Found Guilty Of Motor Vehicle Violations Within The Past 3 Years? (Omit Minor Parking Violations)

YesNo

Year:

Please Explain:

Do You Hold A Driver’s License In Good Standing?

YesNo

State:

License Number:

Authorization and Acknowledgement

I certify that all information I have given on this application, including the attached resume, if any, is accurate and complete to the best of my knowledge. I understand that consideration for employment is contingent upon the results of reference and background reviews, and that any omissions and misstatements on this application and attachments may be grounds for rejection of my application or termination of my employment. I hereby authorize the Company and its agents to investigate the truthfulness of all statements made on my employment application, resume and other attachments. I understand that this investigation may include contacting references, my former employers, confirming my educational attainments, reviewing my motor vehicle records, reviewing any criminal justice records for criminal convictions that relate to me and obtaining a consumer credit report. I give consent for all contacted persons to provide information concerning my application, and I release each such person from liability for providing information to the Company and its agents.

In keeping with the Company’s strong commitment to maintaining a work environment that is free from the harmful effects of drug abuse and safe for its employees and others, I understand that a final offer of employment is conditioned upon a favorable health evaluation (in accordance with Americans with Disabilities Act) and chemical screening for illegal drugs and substance abuse, and that future periodic screenings may be required after employment where there is reasonable suspicion that I am under the influence of alcohol/drugs while on Company premises or engaged in Company business off Company premises, in the event of an accident requiring medical attention or involving serious damage to Company property or equipment. I release and hold harmless the Company, its officers, agents and employees of any liability based upon the request for, administration of, and use of the results of any physical examination and authorize any examining physician /laboratory to disclose the results to the Company or its agents.

I understand that the Company will make reasonable accommodations for a qualified applicant or employee with a disability unless it would cause an undue hardship. It is my obligation if I am disabled to request the Company to make reasonable accommodation.

If hired, I understand that federal law requires competition of an I-9 form establishing my employment eligibility within 3 days of hire.

I understand that nothing contained in this employment application or interview and no Company policies, procedures, correspondence or handbooks that I might receive are intended to create an employment contract between the Company and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon the Company unless made in writing and signed by an officer of the Company. I understand that if I am hired by the Company, I may terminate my employment at any time with or without cause or notice and the Company may do the same.

I have read and agree to the Company’s Authorization and Acknowledgement.