Date of Application  / 12345678910111213141516171819202122232425262728293031 /

How did you learn about us?                                   

Advertisement                        Friend                        Inquiry                           

Employment Agency             Relative                      Other

Last Name                                  First Name                                 Middle Name

Current Address

Number   Street                               City                                  State                         Zip Code

             NoneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeUtahVermontVirginiaWashingtonWashington, DCWest VirginiaWisconsinWyoming    

Telephone                                           Social Security Number

                                 - -

Best time to contact you at home is:                       : Choose..AMPM

If you are under 18 years of age, can you provide              Yes

required proof of your eligibility to work?                             No

Have you ever filed an application with us before?            Yes     

If yes, give date:  / 12345678910111213141516171819202122232425262728293031 /                                  No

Have you ever been employed with us before?                 Yes             

If yes, give date:  / 12345678910111213141516171819202122232425262728293031 /                                   No

Do any of you friends or relatives, other than spouse,       Yes

work here?                                                                              No

If yes, state name(1), relationship(2) and location(3):

1        2       3

Are you currently employed?                              Yes                     No

May we contact your present employer?         Yes                     No

Are you prevented from lawfully becoming employed in this           Yes

country because of Visa of Immigration Status?                                No

    Proof of citizenship or immigration status will be required upon employment.

Date available for work:  / 12345678910111213141516171819202122232425262728293031 /      

What is your desired salary range?   $    to  $

Are you available to work: Full Time (Shift 1,2, or 3 )

                                            Part Time (Morning,Afternon,Night )

                                            Temporary (from / 12345678910111213141516171819202122232425262728293031 /   to / 12345678910111213141516171819202122232425262728293031 / )

Are you currently on "lay-off" status and subject to recall?  Yes       No

Can you travel if a job requires it?                          Yes                     No

Education

School           Name & Address                      Course of Study        Years completed    Diploma/Degree

High School         

Undergraduate        

College                

Graduate/            

Professional

Other (Specify)         

Work Experience

Start with your present or last job.  Include any job-related military service assignments and volunteer activities.  You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.

Employer                                    Dates Employed

Address                                          to 

Telephone Number(s)      

Starting/Present Job Title        Starting Wages

Supervisor                                  to 

Reason for Leaving                Starting       Final

Work Performed

May we contact? Yes      No

Employer                                    Dates Employed

Address                                          to 

Telephone Number(s)      

Starting/Present Job Title        Starting Wages

Supervisor                                  to 

Reason for Leaving                Starting       Final

Work Performed

May we contact? Yes      No

Employer                                    Dates Employed

Address                                          to 

Telephone Number(s)      

Starting/Present Job Title        Starting Wages

Supervisor                                  to 

Reason for Leaving                Starting       Final

Work Performed

May we contact? Yes      No

Employer                                    Dates Employed

Address                                          to 

Telephone Number(s)      

Starting/Present Job Title        Starting Wages

Supervisor                                  to 

Reason for Leaving                Starting       Final

Work Performed

May we contact? Yes      No

Comments: Include explanation of any gaps in employment.

Describe any specialized training, apprenticeship, skills and extra-curricular activities.

Describe any job-related training received in the United States Military.

List professional trade, business, or civic activities and offices  held.                              You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability, or other protected status.

Additional Information

Other Qualifications: Summarize special job-related skills and qualifications acquired from employment or other experience.

Special Skills (Skills/Equipment Operation)

Terminal        Spreadsheet                          Production/Mobile

PC/MAC        Word Processing                    Machinery List

Typewriter      Shorthand                         

           WPM           WPM                              Other List

State any additional information you feel may be helpful to us in considering your application.

Note to the applicant:  DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied?  A review of the activities involved in such a job or occupation has been given.

Yes        No

Personal/Professional References Do not include family members or past supervisors.

    Name                 Phone Number      Best Time to Call        Occupation

1.

2.

3.

Applicant's Statement

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days.  Any Applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this is of an "at-will" nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause.  Is it further understood that this "at-will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.  I understand, also, that I am required to abide by all rules and regulations of the employer.

I have read and hereby understand and acknowledge the terms of the Applicant's statement.

Yes, I Agree                No, I Disagree