Position

Tell us what you're applying for and how you found us.

Position(s) applied for *

Date *

How did you hear about this job?

Where did you hear about this job? *

Why are you seeking a job at this time?

Application Information

Please print clearly.

First name *

Middle

Last *

Street address *

Social Security No.

City / State / Zip *

Phone *

If hired, do you have a means of transportation to get to work? *

Yes No

Describe

Are you at least 18 years old?

Yes No

If under 18, can you furnish a work permit?

Yes No N/A

Driver's License *

This position requires a valid and active driver's license.

License No.

State

Expiration date

Are you legally eligible for employment in the U.S.? *

Yes No

Proof of U.S. citizenship or immigration status is required if hired.

Have you ever been convicted of a crime? *

Yes No

Please state the nature of the offense, including dates and places. *

Are you a veteran?

Yes No

If yes, service from

To

List any special skills or training

Education

List the schools you've attended, most recent first.

Highest grade / level completed *

High school — name

High school — location

College — name

College — location

If in high school, are you enrolled in a recognized co-op program?

Yes No N/A

If yes, identify program and school

Degree & major

Minor

Work History

Please begin with your most recent employer.

Employer {{ emp.num }}

Company

Phone (with area code)

Address

City / State / Zip

Employed from

To

Salary — beginning

Salary — ending

Job title

Supervisor's name & title

Describe duties briefly

Specific reason for leaving

Have you ever worked for any of these organizations or attended school under a different name?

Yes No

Give name and organization(s) *

May we contact the employers listed above?

Yes No

List the employers you do not wish us to contact and why

Employer {{ emp.num }}

Authorizations & At-Will Employment Agreement

Please read carefully, then acknowledge and sign below.

I certify that I have personally completed this application. I declare that the information provided in this employment application is true and complete and I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification for my dismissal from employment if discovered at a later date. I agree to immediately notify this company if I should be convicted of a crime while my job application is pending or during my employment, if hired.

I authorize this company to make an investigation of all information contained in this employment application and I release from liability all companies and corporations supplying such information. I understand any false answers, statements, or implications made by me on this application or other required documents shall be considered sufficient cause for denial of employment or discharge.

I specifically authorize and direct my current and former employers to supply employment-related information to this company and do hereby release my current and former employers from liability for providing information to this company.

Upon termination of my employment for whatever reason, I release this company from all liability for supplying any information concerning my employment to any potential employer.

I authorize this company, if applicable, to request a copy of my credit report, motor vehicle driving record, and any other investigative report deemed necessary through various third party sources. As required by law, upon request within a reasonable period of time, I will be notified as to the nature and scope of such investigations.

I hereby agree to submit to any drug test required of me, whether prior to my employment or if employed by this company at any time thereafter. If requested, I will take a post-job offer physical examination and, in the event I receive medical treatment for any condition, including a physical, psychological, emotional, or psychiatric condition that is job related, I hereby authorize the limited release and exchange of such medical information relating to my condition between the treatment provider and a company-designated physician.

At-Will Employment Agreement. I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract between the company and me. In addition, I understand and agree that if you employ me, in consideration of my employment, my employment and compensation will be at-will, for no definite period of time, and may be terminated at any time, for any reason, or for no reason at all. I understand that only the company's President is authorized to change the employment-at-will status and such a change can only be done in writing. I have read, understand, and agree to the above.

I have read, understand, and agree to the authorizations and the At-Will Employment Agreement above. *

Signature (type your full name) *

Date *

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