Street *

City *

State *

Zip Code *

2. Social Security Number *

3. Position applied for: *

4. Type of employment desired: *

5. Desired Salary: *

6. Date you can start work if hired: *

7a. Monday: Times that I am available to work *

7b. Tuesday: Times that I am available to work *

7c. Wednesday: Times that I am available to work *

7d. Thursday: Times that I am available to work *

7e. Friday: Times that I am available to work *

8. Have you previously applied for employment with this company? *

8a. If you answered yes to question 8, when and where did you apply?

9. Have you ever been employed by this company? *

9a. If you answered yes to question 9, please provide the dates of previous employment, location and reason for separation from employment.

10. Do you have any commitments to any other employer which could effect your employment with this company if hired for example, an employment agreement, a non-competition, or non-solicitation agreement, or conflict of schedule? *

10a. If you answered, yes to question 10, please explain.

11. If hired, can you provide proof that you are a U.S. citizen or legally authorized to be employed in the U.S.? *

12. Are you with or without reasonable accommodation, able to perform the duties of the position for which you are applying? (See copy of job description) *

13. Do you have a valid Driver's License or State ID? *

14. Do you have current Liability Insurance? *

15. Were you referred to this position by a current employee? *

15a. If you answered Yes to question 15, what is the employee's name and what is the nature of your relationship?

15b. If you answered No to question 15, how did you hear about this position?

Note: All applicants who are offered employment are required to complete a livescan background investigation at their expense. Employment will only be finalized once the background check clears. Employees will be reimbursed for the full cost of the livescan upon completion of 30 days of employment with the company. Reimbursement will not be given if you do not meet the 30 day requirment.

16. High School Education: Name and Location *

16a. High School Graduation Date *

17. College Education: Name and Location

17a. College Graduation Date

17b. College Degree Earned

18. College Education: Name and Location

18a. College Graduation Date

18b. College Degree Earned

19. List any professional License/Certifications you have:

20. List any special skills that you feel qualify you for the job in which you are applying:

21. Please describe your computer skills: *

22. Is there any additional information relative to change of name, use of an assumed name, or nickname necessary to enable a check on your work and educational records?

Please list the names of your present or previous employers in choronological order with the most present employer listed first. You may include any verifiable work performed on a volunteer basis or internships.

YOUR FAILURE TO COMPLETELY RESPOND TO EACH INQUIRY MAY DISQUALIFY YOU FOR FUTURE CONSIDERATION OF EMPLOYMENT.

23. Employer:

23a. Street Address:

City:

State:

Zip Code:

23c. Start Date:

23d. End Date:

23e. Phone Number:

23f. Job Title:

23g. Number of Weekly Hours:

23h. Duties:

23i. Reason for leaving:

23j. Supervisor's Name:

23k. May we contact them?

23l. If no, why not?

24. Employer:

24a. Street Address:

City:

State:

Zip Code:

24c. Start Date:

24d. End Date:

24e. Phone Number:

24f. Job Title:

24g. Number of Weekly Hours:

24h. Duties:

24i. Reason for Leaving:

24j. Supervisor's Name:

24k. May we contact them?

24l. If no, why not?

25. Employer:

25a. Street Address:

City:

State:

Zip Code:

25c. Start Date:

25d. End Date:

25e. Phone Number:

25f. Job Title:

25g. Number of Weekly Hours:

25h. Duties:

25i. Reason for Leaving:

25j. Supervisor's Name:

25k. May we contact them?

25l. If no, why not?

33. Please explain fully any gaps in your employment history in excess of one month.

34. Have you ever been terminated or asked to resign from any job?

35. Has your employment ever been terminated by mutual agreement?

36. Have you ever been given the choice to resign rather than be terminated?

37. If you answered Yes to any of the above three questions, please explain the circumstances of each occasion.

38. Name:

38a. Company:

38b. Work Relationship:

38c. Phone Number:

39. Name:

39a. Company:

39b. Work Relationship:

39c. Phone Number:

40. Name:

40a. Company:

40b. Work Relationship:

40c. Phone Number:

41. Name:

41a. Occupation:

41b. Number of years known:

41c. Phone Number:

42. Name:

42a. Occupation:

42b. Number of years known:

42c. Phone Number:

43. Name:

43a. Occupation:

43b. Number of years known:

43c. Phone Number:

E. APPLICANT CERTIFICATION:

I certify that all the information on this application, my resume, or any supporting documents I may present during this interview, is and will be, complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment, or if employed, disciplinary action, up to and including immediate dismissal.
I understand that neither this application nor any communication by a management representative is intended to create nor does create a contract of employment, offer, or promise of employment for a definite term. I understand that if hired by the company, employment is on an at-will basis in accordance with state law. This means the company is free to terminate my employment at any time, with or without cause or advance notice, in accordance with state law, and acceptance of employment is not a contract of employment at any time for any reason. This at-will provision may be modified or waived only in a written agreement by an authorized representative of the company and myself.
I agree to conform to the rules and regulations of the company, and I understand that the company has complete discretion to modify such rules and regulations at any time, except that it will not modify its policy of employment at-will.
I authorize the company or its representative to confirm all statements contained in this application and/or resume as it relates to the position for which I am applying and to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation.
I authorize and consent to, without reservation, any party or agency contracted by this employer to furnish the above-mentioned information. I hereby release, discharge and hold harmless, to the extent permitted by fedral, state, and local law, any party delivering information to the company or its authorized representative pursuant to this authorization from any liability claims, charges, or causes of action, which I may have as the result of the delivery or disclosure of the above requested information. I hereby release from liability the company and its representatives for seeking such information and all other persons, or organizations furnishing such information.
If hired by this company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the U.S. by this company. I also understand this company employs only individuals who are legally eligible to work in the U.S.
I affirm that I own or have ample access to a computer, have an email account, have general knowledge of operation and care of a computer, computer hardware/software, can implement some basic troubleshooting techniques, and have a basic understanding of how to use the internet.
I affirm that I have a valid drivers license without any restricitions, and reliable transportation (with appropriate and valid insurance) to get to and from my designated work location.
THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

44. Print full name: *