Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Position(s) applied for

Date of application

Name

Social Security #

Address (Street, city, state, zip code)

Telephone#

Mobile/Beeper/Other#

E-mail Address

Referral Source (How did you hear about us?)

If you are under 18 and it is required, can you furnish a work permit?

Yes

If no, please explain:

Have you ever been employed here before? If yes, give dates and positions:

Yes

Are you legally eligible for employment in this country?

Yes

Date available for work

What is your desired salary range ($)?

Type of employment desired:

Full-Time

Part-Time

Temporary

Seasonal

Educational Co-Op

Are you able to perform the essential functions of the job for which you are applying (with or without resonable accommodation)?

This question is not designed to elicit information about an applicant's disability. Pelase do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Yes

Need more information about the job's "essential functions" to respond

Driver's license number required if driving may be required in position for which you are applying:

State

Answering "yes" to following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Have you ever pleaded "guilty" or "no contest" to, or been convicted of a crime?

Yes

If yes, please provide date(s) and details:

Employment history

Starting with your most recent employer, provide the following information.

Employer

Telephone#

Street Address

City

State

Starting job title/final job title

Immediate supervisor and title (for most recent position held)

May we contact for reference?

Yes

Later

Why did you leave?

Dates employed:

Compensation (Starting)

Hourly

Salary

per

Commision/Bonus/Other Compensation $

Compensation (Final)

Hourly

Salary

per

Commision/Bonus/Other Compensation $

Summarize the type of work performed and job responsibilities

Skills and Qualifications

Summirize any special training, skills, licenses and/or certificates that may assist you in performing the position for whicch you are applying:

Computer Skill (Check appropriate boxes. Include software titles and years of experience.)

Word Processing

Years

Spreadsheet

Years

Presentation

Years

E-mail

Years

Internet

Years

Other

Years

Educational Background

School (include City & State)	Years Completed	Completed	GPA Class Rank	Major/Minor
		Diploma Degree Certificate Other GED

References

List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you

Name	Title	Relationship to You	Telephone	Number of Years Known

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an 1-9 Form in this regard.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status. The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNTIL, YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

(REQUIRED) I certify that i gave read, fully understand and accept all terms of the foregoing ApplicantStatement

Signature of Applicant

Date

Application for Employment

Employment history

Skills and Qualifications

Educational Background

References

Applicant Statement

DO NOT SIGN UNTIL, YOU HAVE READ THE ABOVE APPLICANT STATEMENT.