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APPLICATION FOR EMPLOYMENT

Date:

* required

First Name:

Last Name:

Address:

City:

State:

ZIP:

How Long ?

Phone Number:

Mobile Number:

Emergency Contact:

Emergency Phone:

Social Security #:

Are you 21 years of age or older?

Are you a U.S. citizen?

Email:

Position Applied For?

Salary desired:

Employment Desired:

Full Time: Part Time: *

Days/Hours available to work: (Be specific:) *

Mon:

Tues:

Wed:

Thurs

Fri:

Sat:

Sun:

How many hours can you work weekly? *

Can you work nights?

Yes No *

Have you ever been convicted of a crime? Yes No *

If yes, explain: Number of conviction (s), nature of conviction (s), how recently such offense (s) was/were committed, sentence (s), imposed, and type (s) of rehabilitation.

When can you start?

Education:

Name of School	Address	Year Graduated	Major/Degree
*	*	*	*

Former Employers – List below your last four employers starting with the most recent:

Month & Year	Company Name Address/Phone Supervisor's Name	Salary	Position	Reason for Leaving
From: To: *	*	*	*	*
From: To:
From: To:
From: To:

May we contact your present/previous employer? Yes No *

Do you have a drivers license? Yes No *

What is your means of transportation? *

References – Please give (3) JOB related references:

Name	Address/Phone	Position	Years Acquainted

Referred by:

Attach Resume:

Attach Additional Documentation:

AUTHORIZATION

I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire or dismissal if I have been employed, no matter when discovered by the Company.

I understand that any employment is conditioned on a background check. I authorize the Company to thoroughly investigate all statements contained on my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, character and general reputation to the Company, without giving me prior notice of such disclosure. In addition, I release the Company, any former employers and any references listed above from any and all claims, demands or liabilities arising out of or related to such investigation disclosure.

I understand and agree that nothing contained in this application or conveyed during any interview is intended to create an employment contract. I further understand and agree that if I am hired my employment will be “at will” and without fixed term, and may be terminated at any time with or without cause and without prior notice at the option of either myself or the Company. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon the Company unless made in writing.

If I am offered employment I agree to submit to a medical examination and drug/alcohol test before starting work. If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by the Company and as permitted by law. I consent to such examination and tests and I request that the examining doctor disclose to the Company the results of the examination, which results shall remain confidential and segregated from personnel files. I understand that my employment or continued employment to the extent permitted by law is contingent upon satisfactory medical examinations and drug tests and if I am hired a condition of my employment will be that I will abide by the Company’s Drug and Alcohol policy.

I understand that filling out this form does not indicate there is a position open and does not obligate the COMPANY to hire. If hired, I agree to abide by all COMPANY work rules, policies and procedures. The COMPANY retains the right to revise its policies or procedures in whole or in part at any time.

I agree that the information provided is true