Employment Application

APPLICATION FOR EMPLOYMENT

Position Applied For

Date of Application

PERSONAL

Name

First Middle Last

Present Address (Street, City, State, Zip Code)

Home Telephone Number

Message Telephone Number

If No Phone, How May We Contact You?

Are Any of Your Relatives Presently Employed With This Business Or Its Divisions?

Yes
No

If Yes, Who?

Have You Ever Worked For This Business Or Its Divisions Before?

Yes
No

If Yes, Where?

Approximate Date: Month/Year

Have You Ever Applied For Employment With This Business Or Its Divisions Before?

Yes
No

If Yes, Where?

Approximate Date: Month/Year

How Were You Referred?

GENERAL INFORMATION

Are You 18 years Of Age Or Older?

Yes
No

Only U.S. Citizens Or Aliens Who Have A Legal Right To Work In The U.S. Are Elgible For Employment. Can You, Upon Employment, Provide Genuine Documentation Establishing Your Identity And Elgibility To Be Legally Employed In The United States?

Yes
No

Please Check Schedule Availability

I am available and desire to work FULL-TIME. Full-Time employees must be available for all/rotating shifts.
I am available and desire to work PART-TIME

Monday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)

Tuesday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)

Wednesday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)

Thursday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)

Friday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)

Saturday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)

Sunday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)

Note: Work Schedules Are Based Upon The Needs Of The Business And May Be Subject To Change On A Weekly Basis.

Wage Expected?

Date Available For Work?

EMPLOYMENT HISTORY

Begin With Your Most Recent Employment (1) And Continue With All Past Employment

Employment History

Employer	Street Address	City, State, Zip Code	Your Title(s)	Employed From (mm/yyyy)	Employed To (mm/yyyy)	Starting Salary ($)	Ending Salary ($)	Your Duties	Reason for Leaving	Name & Title of Supervisor	Phone Number	Type of Business	May We Contact Employer?

Click the + button on the far right to add additional employers

EDUCATION

Education History - List High School and any post High School education. Click the + button on the far right to add additional high schools, colleges, universities, technical colleges, or trade schools

Type of School	Name and Address Of School	Major Subject	Highest Grade Or Year Completed	Graduate?	Degree

Click the + button on the far right to add additional high schools, colleges, universities, technical colleges, or trade schools

Military

Military Training or Experience

Cover Letter

Resume

PERSONAL OR BUSINESS REFERENCES

Add 4 References

Name	Occupation Business Phone Number	Telephone Number	Title/Relationship

Click the + button on the right to add additional references

Other Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.

EEO INFORMATION

To assist us in complying with government record keeping, reporting and other legal requirements, please fill out the form after submitting your application. Providing this information is voluntary and refusal to provide this information will not have a negative effect on your status as an applicant or employee. This information will be kept confidential and in accordance with federal and state regulations.

NOTIFICATION AND AGREEMENT

Applicant Statement

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE, I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR H0W DISCOVERED.

Questions regarding this statement should be directed to any employment interviewer before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

It is the policy of the company to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status, expunged juvenile records, or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State or Local law.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.

If hired, I agree to abide by all of the company rules and regulation, and understand that, if employed, my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either the company or me, I further understand that no representation, whether oral or written by any representative or agent of the Company, at any time, can constitute a contract of employment. I understand that the Company and all Plan Administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment. No representative or agent of the company, has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the President or Executive Vice President, or to make any agreement contrary to the foregoing.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me

Signature (Type your initials)

DO NOT SUBMIT UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

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