Application for Employment

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, handicap, or national origin.

Personal Information

Name

First Middle Last

Present Address

Street City State Zip Code

Permanent Address

Street City State Zip Code

Phone Number

Referred by

Are you 18 years of age or older? Yes □ No□

Employment Desire

Position

Date You Can Start Salary Desired

Are You Employed Now? Yes □ No□

If So, May We Contact Your Present Employer? Yes □ No□

Ever Applied To This Company Before? Yes □ No□

Where? When?

Education

	Name and Location of School	Circle Last Year Completed	Did You Graduate?	Subjects Studied and Degree(s) Received
High School		1 2 3 4	Yes □ No□
College		1 2 3 4	Yes □ No□
Trade, Graduate, Business, or Correspondence School		1 2 3 4	Yes □ No□

General

Subjects of Special Study or Research Work

Job Related Skills (computer, driver’s license, certifications)

Employment History List below your last four employers, start with the last one first

Date Month and Year	Name and Address of Last Employer	Phone Number	Supervisor	Salary Upon Leaving	Position	Reason for Leaving
From
To
From
To
From
To
From
To

References List List below three people not related to you, whom you have known for at least one year

Name	Address	Phone Number	Position	Years Acquainted
1.
2.
3.

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.

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 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 employers and all references listed above from any and all claims, demands, or liabilities arising out of or related to such investigation of 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 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 personnel 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 or procedures, in whole or in part, at any time.

Date Signature