Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodations to the application and/or interview process should notify a representative of the Human Resources Department. Personal Information   Application Date:              Name /Social Security Last First Middle Social Security #  Address Street City State Zip Code   Telephone #      Mobile / Beeper / Other Phone #   Format: (###)  ### - ####  Format: (###)  ### - ####   Email Address  Position(s) applied for   Where did you hear about us? Please check the appropriate category and name the source  Walk-in    School    Employee    Job Fair    Advertisement    Staffing Agency    Company's Website    Government Employment Agency    Other Internet    Other   General Employment Information May we contact you at work?  Yes    No     If  yes,  work number and best time to call: Phone:   Time:    AM    PM       If you are under 18 and it is required, can you furnish a work permit?   Yes      No     If  no,  explain:   Have you submitted an application here before?  Yes    No     If  yes,  give date and position: Date:   Position:     Have you been employed here before?  Yes    No     If  yes,  give dates: From:   To:     Are you legally eligible for employment in this country?  Yes    No       Date available for work:   What is your desired salary range or hourly rate of pay? $   Per:     Type of work desired: Full-Time   Part-Time   Educational Co-Op   Seasonal   Temporary   Will you relocate if job requires it?  Yes    No     Will you travel if job requires it?  Yes    No     If they have been explained to you, are you able to meet the attendance requirements for the position? N/A Yes No Will you work overtime if required?   Yes      No     If  no,  explain:   Driver's license number (Required if driving may be required in the job for which you are applying): License Number:   State:     Employment History Starting with your most recent employer, provide the following information. Most Recent Employer      Dates Employees (Mo/Yr):  -    FromTo Compensation (Starting)  Hourly   Salary   $   Per:     Commission/Bonus/Other   $   Compensation (Ending)  Hourly   Salary   $   Per:     Commission/Bonus/Other   $   EmployerTelephone       StreetCityState  /  Starting job title / Final job title Yes No Later Immediate supervisor and title (for most recent position)    May we contact for reference? Why did you leave? Summarize the type of work performed and job responsibilities. What did you like most about your position? What were the things you liked least about your position? Previous Employer        Dates Employees (Mo/Yr):  -    FromTo Compensation (Starting)  Hourly   Salary   $   Per:     Commission/Bonus/Other   $   Compensation (Ending)  Hourly   Salary   $   Per:     Commission/Bonus/Other   $   EmployerTelephone       StreetCityState  /  Starting job title / Final job title Yes No Later Immediate supervisor and title (for most recent position)    May we contact for reference? Why did you leave? Summarize the type of work performed and job responsibilities. What did you like most about your position? What were the things you liked least about your position? Previous Employer        Dates Employees (Mo/Yr):  -    FromTo Compensation (Starting)  Hourly   Salary   $   Per:     Commission/Bonus/Other   $   Compensation (Ending)  Hourly   Salary   $   Per:     Commission/Bonus/Other   $   EmployerTelephone       StreetCityState  /  Starting job title / Final job title Yes No Later Immediate supervisor and title (for most recent position)    May we contact for reference? Why did you leave? Summarize the type of work performed and job responsibilities. What did you like most about your position? What were the things you liked least about your position? Previous Employer      Dates Employees (Mo/Yr):  -    FromTo Compensation (Starting)  Hourly   Salary   $   Per:     Commission/Bonus/Other   $   Compensation (Ending)  Hourly   Salary   $   Per:     Commission/Bonus/Other   $   EmployerTelephone       StreetCityState  /  Starting job title / Final job title Yes No Later Immediate supervisor and title (for most recent position)    May we contact for reference? Why did you leave? Summarize the type of work performed and job responsibilities. What did you like most about your position? What were the things you liked least about your position? Gaps in Employment Explain any gaps in your employment, other than those due to personal illness, injury or disability:   If not addressed on a previous page, have you ever been fired or asked to resign from a job?     Yes    No   If yes, please explain:   Skills and Qualifications   Summarize any special training, skills, licenses, and/or certifications that may assist you in performing the position for which you are applying.     Computer Skills (Check appropriate boxes. Include software titles and years of experience)  Word Proc.      yrs  Internet      yrs  Spreadsheet      yrs  Other      yrs  Presentation      yrs  Other      yrs  Email      yrs  Other      yrs   Educational Background Starting with your most recent school, provide the following information. School (Include City & State) Completed Major/Minor & GPA  Diploma   GED  Degree   Cert.      Other    Major/Minor: GPA:    Diploma   GED  Degree   Cert.      Other    Major/Minor: GPA:    Diploma   GED  Degree   Cert.      Other    Major/Minor: GPA:    Diploma   GED  Degree   Cert.      Other    Major/Minor: GPA:     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 were not related to you. Name Title Relationship Years Telephone   Related Information List special accomplishments, publications, awards, etc. Exclude information that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard, or any other protected status. Is there any other job-related information you want us to know about you?   Applicant Statement I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employers 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 to 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 any 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 prior notice, and the employer reserves the same right to terminate any 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 I-9 Form in this regard. 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. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.