Are you at least 18 years old?

Yes:

No:

Are you authorized to work in the US?

Yes:

No:

Do you now, or will you in the future, require sponsorship for employment visa status?

Yes:

No:

Date you can start work:

Position Desired:

Full-time:

Part-time:

Shift a availability (check all that apply):

Day:

Evening:

Night:

Rotating:

Day availability (check all that apply):

Mon:

Tues:

Wed:

Thurs:

Fri:

Sat:

Sun:

Overtime availability:

Yes:

No:

Have you applied for employment with the company before?

Yes:

No:

If so:

Date:

Position:

Have you ever worked for the company before?

Yes:

No:

If so:

Date:

Position:

Location:

Are you related (by blood, marriage, or law) to anyone who works for the company?

Yes:

No:

If so:

Name:

Location:

Have you ever been involuntarily terminated or asked to resign from employment?

Yes:

No:

If so, give the name of the employer, dates of employment, position held, name of supervisor, and reason for termination/resignation request:

Have you ever been counseled, disciplined, terminated or asked to resign as a result of reported workplace harassment, fighting/ assault, violation of safety rules, or other inappropriate condition?

Yes:

No:

If so, give the name of the employer, date and description of incident:

List your complete employment history, including military service, starting with your present status. All periods of unemployment must be identified as “Unemployed” and dates if unemployment identified. Do not leave time gaps. If necessary, use Supplement Employment History from to provide all information.

Name of employer:

Position(s) held, salary, supervisor and dates:

Address/phone number of location where you worked:

Reason for leaving:

Name of employer:

Position(s) held, salary, supervisor and dates:

Address/phone number of location where you worked:

Reason for leaving:

Name of employer:

Position(s) held, salary, supervisor and dates:

Address/phone number of location where you worked:

Reason for leaving:

High School:

Yes:

No:

College:

Yes:

No:

Trade School:

Yes:

No:

Graduate School:

Yes:

No:

(List 2. Do not list relatives, domestic partners, or former employers.)

Name:

Occupation:

Complete Address:

Phone Number:

Dates Known:

Name:

Occupation:

Complete Address:

Phone Number:

Dates Known:

Have you ever been convicted of (or pleaded guilty or no contest or paid a five for) ANY criminal offense of ANY type whatsoever (this includes but is not limited to felonies, misdemeanors, DWI, hunting offenses, domestic, city or county ordinances)?

Yes:

No:

If so, list all offense(s), date(s) of conviction/plea, county/city of conviction:

List all professional licenses, certifications, etc., that may be related to the position you are applying for and list dates issued and name of the organization granting the license, certification, etc.

List and describe any special skills, second languages, or other training you have that may be related to your employment

I certify that the information provided on this application form, along with all other information I have provided to the company, is accurate and complete. I understand that any misrepresentations or omissions will be cause for not hiring me or for terminating my employment, once hired.

I understand that the company will undertake, and I authorize the company to undertake, any investigation it deems necessary in considering me for employment or, if hired, my continued employment. I expressly authorize any present or former employer; school, college, or university; utility company; credit or finance bureau; personal reference; chief law enforcement officer; any member or any local state, or federal law enforcement agency; or any other person to give the company any information (written or oral) or records concerning me or my qualifications, employment (including but not limited to the reasons for my termination), credit, reputation, mode of living, education, or criminal record. I unconditionally release the company and its representatives and agents and all persons from whom they request information from any and all liability relating to such request for information or any information provided.

I understand that this application will be active only for the specific position identified above and only during the period the company is seeding to fill the current opening(s), and that any job offer, or if hired, my continued employment, may be conditioned upon a medical examination and/or alcohol or drug testing.

I understand that, if hired, my employment will be strictly at will. That means my employment is for an indefinite period and that the company or I may terminate the employment at any time, for any or no reason, with or without notice or intermediate steps. I further understand that no verbal statements or statements in any company policy or procedure manual, employee handbook, or other document shall be construed to have altered the at will nature of my employment. No company manager or representative shall be authorized to make any representations to the contrary.

Signature:

Date: