Employment

It is the policy of this company to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status. The purpose of this application is to gather information, evaluate applicants, and if a position becomes available, request an interview with such applicant to determine weather applicant, job skills, and job requirements are compatible.

Applicant Information:

Applicant Name:
Address:
City/State/Zip:
Number of years at this address:
Daytime phone:
Evening phone:
E-Mail:
Social Security Number:
Driver's License Number:
What state issued your license?

Who should be contacted if you are involved in an emergency?

Contact Name:
Relationship to you:
Address:
City/State/Zip:
Daytime ph:
Evening ph:

Please provide the following personal information:

Position Applied For:
Salary Desired:	per month
Who referred you to our company?
Have you applied to our company previously?
If yes, when?
Are you at least 18 years old?
How will you get to work?
Are you willing to work any shift, including nights, weekends, and midnight?
If no, please state any limitations:
If you were offered employment, when would you be available to begin work?
What languages are you fluent in?	English Spanish Other

Are you legally eligible for employment in the United States?
Have you ever been convicted of any crime, including traffic violations?
If yes, please describe:
Note:	The Existence Of A Criminal Record Does Not Constitute An Automatic Bar To Employment Unless Relevant To The Type Of Employment.

Applicant Employment History: (List your current or most recent employment first)

Employer Name:
Address:
City/State/Zip:
Job Duties:
Reason for Leaving:
Dates of Employment (Month/Year):

Employer Name:
Address:
City/State/Zip:
Job Duties:
Reason for Leaving:
Dates of Employment (Month/Year):

Employer Name:
Address:
City/State/Zip:
Job Duties:
Reason for Leaving:
Dates of Employment (Month/Year):

High School Name:
Last Grade?
Diploma?
College Name and Address:
Did you receive a degree?
If yes, degree received:
Other Training (graduate, technical, vocational):

References: List any two people who would be willing to provide a reference for you.

Name:

Address:
City/State/Zip:
Telephone:
Relationship:

Name:
Address:
City/State/Zip:
Telephone:

Relationship:

Please Provide any additional information you feel should be considered:

CERTIFICATION:

I certify that the information provided on this Application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my Application, or if employment commences, immediate termination.

I authorize the company to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its President, or Vice-President, the employment relationship will be entirely voluntary in nature. In other words, with appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer would have the same right. Moreover, no agent, representative, or employee of the company, except in a specific written contract of employment signed on behalf of the organization by its President, or Vice-President, has the power to alter or vary the voluntary nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

I Agree I Disagree