(This company is an equal employment opportunity employer. All applicants will be considered without regard to age, color, national origin, religion, disability, sex, or other protected status in accordance with applicable federal and state equal employment opportunity laws. This company will strive to accommodate any physical or mental limitations of employees or applicants in order to accomplish the essential functions of a job.)

GENERAL INFORMATION

Full Name:

Street Address:

City & State:

Zip Code:

E-mail address:

Phone Number: () - -

Date to Start:   /  / mm/dd/yyyy

Type of work desired:

If employed and under 18, can you furnish a work permit?
Yes No Not Applicable

Have you ever been employed by this company?
Yes No

Are you employed now?
Yes No

May we contact your present employer?
Yes No

Are you prevented from lawfully becoming employed in this
country because of Visa or Immigration status?
Yes No

Do you have a valid driver's license in this state?
Yes No
License #:

Can you perform the essential functions of the job(s) for
which you are applying?
Yes No

Are you available to work:
Full-Time Part-Time Over-Time

Have you been convicted of a felony?
Yes No
(Please note that a "Yes" answer will not bar you from consideration for employment.)

If Yes, please explain:

EDUCATION

Highest level of education:
School name:
City/State:
Years completed:
Concentration:

Special Skills, qualifications and considerations:

Reference One:
Occupation/Relationship:
Years Known:
Phone Number: () - -

Reference Two:
Occupation/Relationship:
Years Known:
Phone Number: () - -

Reference Three:
Occupation/Relationship:
Years Known:
Phone Number: () - -

EMPLOYMENT EXPERIENCE

If you would like to send along your current resume, you may send it seperately and include your name in the subject line.

Or you may fill in your previous employers below:

Most Recent Employer:
Phone Number: () - -
-Position Held:
-Time Length:
Starting Wage: Ending Wage:

Previous Employer:
Phone Number: () - -
-Position Held:
-Time Length:
Starting Wage: Ending Wage:

Previous Employer:
Phone Number: () - -
-Position Held:
-Time Length:
Starting Wage: Ending Wage:

Please read the following statements carefully before submitting this application. Only those applications that are signed and dated are considered valid (once submitted in person). If you have any questions regarding this statement, please ask them before submitting.

I certify that all answers and statements I have made on this application (and resume or other supplementary materials) are true and complete without omissions. I understand that any false information will be grounds for refusal to hire or for immediate discharge if I am employed. I authorize any of the persons or organizations named in this application to give you complete information and records regarding my employment, education, character and qualifications, including driving and/or credit history.
Yes No

If hired I will be responsible for familiarizing myself with all rules and regulations of the company as they presently exist or are later modified. If hired I recognize that my employment can be terminated, at the discretion of the company or at my option, without notice, at any time, except as specifically set forth in writing in a current individual employment agreement.   
Yes No

I also understand that no representative of the company has any authority to enter into any employment agreement for any specified period of time, or to assure me of any future position, benefits, or terms and conditions of employment, except as specifically stated in a current written agreement signed by the President.
Yes No

I understand this application is not an offer of employment and no promises or representations of employment have been made to me at this time.
Yes No

I have read, understand, and agree with the above.
Yes No