Employment Application

Position Desired:
When can you report?
Salary Desired:
Date of Application:
PERSONAL INFORMATION
This facility is an Equal Opportunity Employer.
Last*
First*
Middle Initial
Social Security Number:

This is not a secure form.
Home Phone*
Street Address*

Apartment #
City*
State*
Zip*
Work Phone
Email
Cell Phone
Do you have relatives working for the company?
- No
- Yes
If yes, list names:
How were you referred to the company?
Have you worked for the company before?
- No
- Yes
Are you anticipating absences away from work of any duration?
- No
- Yes
Explain:
Are you available to work overtime, if necessary?
- No
- Yes
Are you able to work weekends?
- No
- Yes
Are you able to travel?
- No
- Yes
Do you have reliable means of transportation to and from work?
- No
- Yes
Explain:
For driving jobs only: Do you have a drivers license?
- No
- Yes
If yes, please provide license #, state and expiration date:
If driving is a requirement of the position applied for, have you had your license suspended or revoked in the last 3 years?
- No
- Yes
If yes, please explain:
Availability to work:
- Full Time
- Part Time
- Temporary
If part-time list the number of hours you can work per week:
If temporary, available through?
If necessary, are you able and available to work any of the following:
Overtime? Overnight? Holidays Evenings? Weekends? Business Travel?

Type yes or no for each option.
Can you present evidence of your U.S. citizenship or proof of your legal right to work in this country?
- No
- Yes
If hired, proof of lawful right to work in the U.S. will be required.
Are you 18 or older?
- No
- Yes
If hired, can you show proof of age?
- No
- Yes

PROFESSIONAL REFERENCES
In the spaces below, list three people not related to you who have knowledge of your work performance within the last three years.
Reference 1:
Name Occupation/How do you know this person? Phone Number Email Years Known
Reference 2:
Name Occupation/How do you know this person? Phone Number Email Years Known
Reference 3:
Name Occupation/How do you know this person? Phone Number Email Years Known
Affidavit
Put your initials under each section.
I certify that all the information provided in this employment application and supplementary application are true and complete. I agree to have any of the statements checked by the Company unless indicated to the contrary. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

Initial above
I am aware that a more detailed investigation concerning background and credit may also be conducted upon a contingent offer of employment, I hereby authorize that investigation. I also understand that employment is contingent upon satisfactory completion of reference checks and the provision of satisfactory proof of an applicant's identity and legal authority to work in the United States.

Initial above
I understand that if I am extended an offer of employment, it may be conditioned upon my successfully passing a pre-employment alcohol and drug screening examination. I understand that my job offer or my continuing employment, if hired, is contingent upon my being physically, mentally and medically able, with or without reasonable accommodation, to successfully perform the essential functions of my job. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

Initial above
I understand that nothing in this application, conveyed during any interview, or subsequent employment creates a contract of employment between the Company or any subsidiary or affiliate and myself, nor guarantees employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without cause or notice by either myself or the Company. I. understand that the Company can change benefits, policies and conditions at any time.

Initial above.
I understand that any and all disputes regarding my employment with the Company, including any disputes relating to the termination of my employment, are subject to the Alternative Dispute Resolution process, which includes final and binding arbitration. I also understand and agree, as a condition of employment, to submit any such disputes for resolution under that process, and I further agree to abide by and accept the decision of the arbitration panel as the final binding decision and resolution of any such disputes I may have.

Initial above
I understand that the Company may be required to participate in E-Verify. If so, the Company will provide the federal government with my Form I-9 information to confirm that I am authorized to work in the U.S. If E-Verify cannot confirm that I am authorized to work, the Company is required to give me written instructions and an opportunity to contact Department of Homeland Security (DHS) or Social Security Administration (SSA) so I can begin to resolve the issue before the Company can take any action against me, including terminating my employment. The Company can only use E-Verify once I have accepted a job offer and completed the Form I-9.

Initial above
Please read each statement above carefully before signing your name below.
I have read, understand, and by my signature (typed below counts as my legal signature) consent to these statements.
Applicant's Signature

By typing your name above that counts as your legal signature.
Date:
Resume
Accepted file types: pdf, doc, docx, Max. file size: 64 MB.
Please attach your resume here.

High School Name	Location	Years/Grade Completed	Unit Credits	Graduated? Completed?	Major/Degree Earned

Jr College Name	Location	Years/Grade Completed	Unit Credits	Graduated? Completed?	Major/Degree Earned

College Name	Location	Years/Grade Completed	Unit Credits	Graduated? Completed?	Major/Degree Earned

Business Trade Name	Location	Years/Grade Completed	Unit Credits	Graduated? Completed?	Major/Degree Earned

PERSONAL INFORMATION

Education

Military

SKILLED/ADDITIONAL INFORMATION

Additional Information

EMPLOYMENT HISTORY

EMPLOYMENT #1

EMPLOYMENT #2

EMPLOYMENT #3

PROFESSIONAL REFERENCES

Affidavit

Please read each statement above carefully before signing your name below.

SERVICES

CONTACT

Company

Overtime?	Overnight?	Holidays	Evenings?	Weekends?	Business Travel?

Name	Occupation/How do you know this person?	Phone Number	Email	Years Known