Last Name
Social Security #
E-Mail Address          
Address        
Address 2        
Zip
Have you ever been convicted of crime? Are you 18 years or older? If you are under 18 can you furnish a work permit?
Yes
No
Yes
No
Yes
No
Are you legally eligible for employment in this country? Will you work overtime if required? Are you able to meet the attendance requirements?
Yes
No
Yes
No
Yes
No
Do you have reliable transportation? Are you willing to work weekends? If no, please explain:
Yes
No
Yes
No

Education or Training
Starting with your most recent school attended, provide the following information.

School (City & State)

Number of years completed

Achieved
Comments
GED
Diploma
Degree
GED
Diploma
Degree
GED
Diploma
Degree

Employment history      
  Begin with your current job in descending order

Date Month and Year
Name, Address & Phone number of Employer
Salary (upon leaving)
Position
Reason for Leaving
References        
List below three persons not realated to you, whom you have known at least one year
Name
Address & Phone Number
Position
Years Acquainted
List any additional information you would like us to consider

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representative, for seeking gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on the basis prohibited by applicable local, state or federal law. I understand that this application remains on file for only 30 days. At the conclusion of of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as my be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to foregoing express language are valid unless they are in writing and signed by the employer's president. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.


I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (I) cancel further consideration of this application, or (II) immediately discharge me from the employer's service, whenever it is discovered.