Name (Last, First, Middle Initial)

Date

Street Address

Phone

City/State/Zip

Email

Position Applied For

Desired Salary

Referred by

Date Available for Work

Are you legally eligible to work in the United State of America? Are you legally eligible to work in the United State of America? YES NO

Are you at least 18 years of age? YES or NO Are you at least 18 years of age? YES or NO YES NO

Have you ever served in the United States Armed Forces? Have you ever served in the United States Armed Forces? YES NO

If YES to serving in the Armed Forces, please specify dates

Have you ever been convicted of a crime? (NOTE: do not include convictions that were expunged pursuant to a court order) Have you ever been convicted of a crime? (NOTE: do not include convictions that were expunged pursuant to a court order) YES NO

If YES, please describe the nature of the criminal charge and the disposition of the action. (NOTE: Answering YES and providing details to this question does not constitute an automatic bar from employment. Factors such as date of incident, type of incident, seriousness of and nature of the violation, rehabilitation, and position applied for will be taken into consideration).

Do you have a valid Driver's License in the state in which you are applying for employment? Do you have a valid Driver's License in the state in which you are applying for employment? YES NO

Please provide the Type/Number and State of your Driver's License

Do you have any current driving restrictions or a suspended license? Do you have any current driving restrictions or a suspended license? YES NO

If YES, please describe the nature of the driving restriction or suspended license

Have you been convicted of any moving violations (vehicle and/or traffic) in the past five years? Have you been convicted of any moving violations (vehicle and/or traffic) in the past five years? YES NO

Have you been convicted of any alcohol or drug related charges in the past five years? Have you been convicted of any alcohol or drug related charges in the past five years? YES NO

If YES to either of the above questions, please explain

Have you ever been fired or asked to resign from a job? Have you ever been fired or asked to resign from a job? YES NO

If YES, please explain

Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation? Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation? YES NO

List any special skills you have that are related to the job for which you are applying

List any Professional/Technical licenses, certifications, or ratings applicable to the job for which you are applying

EDUCATION: High School

High School Location: City and State

EDUCATION: Vocational

Vocational School Location: City and State

Vocational: Course of Study

Vocational Diploma or Degree Vocational Diploma or Degree YES NO

EDUCATION: College

College Location: City and State

College: Course of Study

College Diploma or Degree College Diploma or Degree YES NO

FORMER EMPLOYER: Name

Phone

Address (Street address, City, State, Zip)

Employment Start Date

Employment End Date

Job Title

Ending Salary

Supervisor's Name

May we contact? May we contact? YES NO

Describe Job Duties

FORMER EMPLOYER: Name

Phone

Address (Street address, City, State, Zip)

Employment Start Date

Employment End Date

Job Title

Ending Salary

Supervisor's Name

May we contact? May we contact? YES NO

Describe Job Duties

FORMER EMPLOYER: Name

Phone

Address (Street address, City, State, Zip)

Employment Start Date

Employment End Date

Job Title

Ending Salary

Supervisor's Name

May we contact? May we contact? YES NO

Describe Job Duties

PROFESSIONAL REFERENCE 1: Name

Phone

Email Address

Relationship

Years Known

PROFESSIONAL REFERENCE 2: Name

Phone

Email Address

Relationship

Years Known

PROFESSIONAL REFERENCE 3: Name

Phone

Email Address

Relationship

Years Known

APPLICANT ACKNOWLEDGMENT, AGREEMENT AND AUTHORIZATION (PLEASE READ CAREFULLY BEFORE SIGNING) I certify that all of the information provided by me in this application, in any other documents submitted in connection with my employment and in any job interviews is correct, accurate and complete to the best of my knowledge. I understand that falsification, misrepresentation, or omission of any facts in said documents or interviews will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.I understand that employment with the Company is “at will,” meaning that if I am hired, I may terminate my employment at any time, with or without cause or prior notice, and the Company may do the same. I understand that, if offered a position within the Company I may be required to submit to a pre- employment drug screening and background check as a condition of employment. I understand that an unsatisfactory result from, refusal to cooperate with, or any attempt to affect the results of pre-employment testing and/or checks will result in withdrawal of any employment offer or termination of employment, if already employed. I further understand that, if I am hired, I may be required to submit to random, post-accident or “for cause” drug testing, or to other drug testing as provided by company policy, during the course of my employment with the Company. I hereby authorize any and all schools, former employers, references, courts, and any others who have information about me, to provide such information to the Company and/or its representatives, agents or vendors. I release all parties involved from any and all liability for any and all claims or damages that may result from requesting or providing such information. If I am hired, in consideration for my employment with the Company, I agree to conform to the rules, regulations, policies and procedures of the company at all times and understand that such conformation is a condition of continued employment. I understand that attendance and punctuality are considered essential requirements for all company positions and that poor attendance or tardiness will result in disciplinary action. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND AGREE TO THE TERMS ABOVE.

APPLICANT SIGNATURE

DATE