EMPLOYMENT APPLICATION

Equal Opportunity Employer: The Company is an equal opportunity employer. Applicants are considered for positions without discriminating on the basis of race, color, religion, national origin, ancestry, sex (including gender identity or expression), sexual orientation, age, disability, genetic information, marital status, arrest and court record, credit history, reproductive health decision, domestic or sexual violence victim status, veteran/military status, citizenship status, or any other characteristic protected by federal, state, or local law.

NAME

EMAIL ADDRESS

CONTACT PHONE

Home/Mailing Address

City

State

Zip Code

Position Desired

ARE YOU ABLE TO PERFORM ESSENTIAL FUNCTIONS WITH OR WITHOUT REASONABLE ACCOMMODATION?

Date Available

May we contact your present employer?

DO YOU KNOW ANYONE CURRENTLY WORKING FOR OUR COMPANY?

IF SO, WHO?

Education

High school, college or technical training

City & state

Years

Degree or certificate

High school, college or technical training

City & state

Years

Degree or certificate

High school, college or technical training

City & state

Years

Degree or certificate

REFERENCES (NOT RELATIVES)

NAME

ADDRESS

OCCUPATION

TELEPHONE NUMBER

NAME

ADDRESS

OCCUPATION

TELEPHONE NUMBER

NAME

ADDRESS

OCCUPATION

TELEPHONE NUMBER

WORK EXPERIENCE

list below previous employers, beginning with the most recent

Employer

Job Title

From

Address

City

State

Zip Code

Phone

Name Of Supervisor

Reason For Leaving

Last Salary

Employer

Job Title

From

Address

City

State

Zip Code

Phone

Name Of Supervisor

Reason For Leaving

Last Salary

Employer

Job Title

From

Address

City

State

Zip Code

Phone

Name Of Supervisor

Reason For Leaving

Last Salary

Employer

Job Title

From

Address

City

State

Zip Code

Phone

Name Of Supervisor

Reason For Leaving

Last Salary

NOTE

It is the policy of this Company to hire only U. S. citizens and aliens who are authorized to work in this country. (As a condition of employment, you will be required to produce original documents establishing your identity and authorization to work, and to complete the U.S. Immigration and Naturalization Service’s Form I-9.)

ACKNOWLEDGEMENTS

By signing below, I certify that all statements made on this application are true and complete to the best of my knowledge. I understand that my application will not be considered if it is incomplete. Further, I understand that any misrepresentation or omission made herein, when discovered, may subject me to discharge. I authorize the Company to investigate my work history, education, character, reputation, and background as it deems necessary for purposes of considering my application for employment. In exchange for the Company’s consideration of my application for employment, I hereby release the Company and all providers of information (including, but not limited to, any of my former employers, educational institutions attended, and personal references) from all liability relating to or arising out of any inquiry by the Company regarding my work history, education, character, reputation, and background.

After an offer of employment is made, but before employment duties begin, applicants may be required to undergo a physical or medical examination (or drug test) at Company expense and by a Company-chosen physician, with the offer of employment conditioned on the result of such examination. Employees, at any time during the course of their employment, may be required to undergo a medical (or drug) examination at Company expense and by a Company-chosen physician. I agree to provide the Company with any authorization or release which may be required for a pre-employment medical examination or drug test.

This application is not a contract of employment and cannot create a contract of employment for any specific period. I understand that if I am employed, my employment is “at will” and can be terminated at any time, either by myself or the Company, with or without cause or reason and with or without notice. Only the President is authorized to modify the Company’s at-will employment policy or enter into any agreement contrary to this policy. Any such modification must be in writing and signed by the employee and the President.

This application will only be considered for three months. I understand that if I have not been hired within three months of completing this application, and I still wish to be considered for employment, I must complete another application

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