Employment

POSITION APPLYING FOR

Date

PERSONAL INFORMATION

Full Name *

Street Address *

City *

State *

Zip Code *

Home Phone *

Cell Phone

Your Email *

Driver's License Number *

Are you Eligible for employment in the United States?
 yes no

United States Visa status, if applicable

Have you been convicted of a felony?
 yes no

If yes, please explain circumstances

Are you at least 18 years old?
 yes no

POSITION INFORMATION

Position(s) applying for

Salary desired

Employment status desired
 Full Time Part Time Temporary

What hours are you available to work?

If hired. When could you start?

How did you hear about th is job?

EMPLOYMENT HISTORY

Job 1

Job Title

Duties

Employer

Dales of Employment (month I year)
From: To:

Starting Salary

Ending Salary

Employment status
 Full Time Part Time Temporary

Employer's Address

Supervisor

May we contact?
 yes no

Phone

Reason for Leaving

Job 2

Job Title

Duties

Employer

Dales of Employment (month I year)
From: To:

Starting Salary

Ending Salary

Employment status
 Full Time Part Time Temporary

Employer's Address

Supervisor

May we contact?
 yes no

Phone

Reason for Leaving

Job 3

Job Title

Duties

Employer

Dales of Employment (month I year)
From: To:

Starting Salary

Ending Salary

Employment status
 Full Time Part Time Temporary

Employer's Address

Supervisor

May we contact?
 yes no

Phone

Reason for Leaving

EDUCATION

High School

Name and Location

Dates Attended

Degree Received

Subject Studied

Did you Graduate?

College / University

Name and Location

Dates Attended

Degree Received

Subject Studied

Did you Graduate?

Graduate School

Name and Location

Dates Attended

Degree Received

Subject Studied

Did you Graduate?

Tech School

Name and Location

Dates Attended

Degree Received

Subject Studied

Did you Graduate?

Special courses, training or experience acquired , including military experience

SKILLS

Clerical I Office skills

Computer skills (Name of Software)

Type of Computer
 PC MAC WPM

Languages

Other special knowledge or skills

CERTIFICATION & AUTHORIZATION

If you are to be hired by the company, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements.

I certify that the facts contained in this application 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 the background check. I authorize the Company to thoroughly investigate all statements contained in 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 employees and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or 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 test before starting to 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 examinations 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 my personal file. I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drug test, and if I am hired a condition of my employment will be that I 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 and procedures, in whole or in part, at any time.

I hereby·acknowledge that I have read and fully understand the forgoing and seek employment under these conditions.

I Agree to the terms above

Signature Name (Required) *