EMPLOYMENT APPPLICATION FORM

Type of employment desired:     Full Time         Part Time

Date available for work:

Have you ever been convicted or presently charged with a violation of federal, state, county or municipal laws

or ordinances (other than minor traffic violations)? Include conviction under court martial and non-judicial punishment

while in the U.S. Military Service.

Yes         No             If yes, give date, place, charge, and disposition:

NOTE: A CONVICTION WILL NOT NECESSARILY BAR YOU FROM EMPLOYMENT. EACH CONVICTION WILL BE JUDGED ON ITS OWN MERIT WITH RESPECT TO TIME, CIRCUMSTANCES, AND SERIOUSNESS.

Do you have a valid driver’s license? (Required for some positions)                         Yes         No

Has your driver’s license been suspended or revoked in the last three years?         Yes         No     If yes, explain

EMPLOYMENT HISTORY:

List your previous employers, assignments or volunteer activities starting with the most recent, including military experience.

May we contact your current or previous employer(s)?   Yes         No

Professional Licenses, Registrations, and/or Certifications

SKILLS AND QUALIFICATIONS:

Summarize special skills and qualifications that may have been acquired from previous employment or other experiences that may qualify you for work with our organization:

REFERRAL SOURCE:

AVAILABILITY:

REFERENCES:

APPLICATION CERTIFICATION AGREEMENT:

I authorize the investigation of all statements contained in this application and release from all liability any persons or employers supplying such information, and I also release the company from all liability that might result from making the investigation.

I certify that the facts and information set forth in this application are true and complete to the best of my knowledge. I understand that falsification, misinterpretation, or omission of facts on this application (or on any required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.

I agree, if I am offered and accept a position, to conform to all existing and future company rules and regulations and I understand that the company reserves the right to change wages, hours and working conditions as deemed necessary. I ALSO UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT WILL BE AT-WILL, MEANING THAT EITHER PARTY CAN END THE EMPLOYMENT RELATIONSHIP AT ANY TIME AND FOR ANY OR NO REASON.

I understand that any employment offer is contingent upon my providing, within (3) working days of employment, valid proof of identity and eligibility to work in order to comply with the Immigration Reform and Control Act of 1986 and completing the drug test.

I have read and reviewed the information provided in this application and the above statements. By signing this application for employment I certify that I understand all parts of it and have answered all questions completely.

By typing your name below, you agree that this is valid as your signature and you have read and agree to the above statement.

Electronic Signature:         Date:

THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT but merely is intended to evaluate suitability for employment. We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/national guard status of any similarly protected status. Or any similarly protected status. It is also the policy of the company to have the option of conducting pre-employment screening before a job offer is made. If a job offer is made, employment may be contingent upon the successful completion of a medical examination, which may include providing body substance samples. This application will remain active for 180 days.