We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.
1. Position Desired
Position
Date of Application

How Did You Learn About Us?

 Advertisement
Friend
Walk-In
Employment Agency
Relative
Other
2. Personal Information
Name (Last, First, Middle Initial)
Social Security Number
Phone Number (Day, Evening) ( ) ( )
Home Address
Street Address
City/State/Zip / /
Mailing Address (if different from home address)
Street Address
City/State/Zip / /
Additional Information

If you are under 18 years of age, can you provide required proof of your eligibility to work?

 Yes No

Have you ever filed an application with us before?

 Yes No
If Yes, give date / / (month / day / year)

Have you ever been employed with us before?

 Yes No
If Yes, give date / / (month / day / year)

Are you currently employed?

 Yes No

May we contact your present employer?

 Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Proof of citizenship or immigration status will be required upon employment.

 Yes No

On what date would you be available for work?

 / / (month / day / year)

Are you available to work:

Full Time Part Time Shift Work Temporary

Are you currently on “lay-off” status and subject to recall?

 Yes No

Can you travel if a job requires it?

 Yes No

Have you been convicted of a felony within the last 7 years? Conviction will not necessarily disqualify an applicant from employment.

 Yes No
If Yes, please explain
3. Education
 

Name and Address of School
Course of Study

Years Completed

Diploma Degree
Elementary School
High School

Undergraduate College

Graduate Professional

Other (Specify)

Indicate any foreign languages you can speak, read and/or write
 
Fluent
Good
Fair
Speak
Read
Write

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

Describe any job-related training received in the United States military.
4. Employment History

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
Employer
Address
City, State, Zip / /

Telephone Number(s)

 ( )

( )

Hourly Rate/Salary

Starting Final
Dates of Employment to
Job Title
Supervisor
Reason for Leaving

Work Performed
Employer
Employer
Address
City, State, Zip / /

Telephone Number(s)

 ( )

( )

Hourly Rate/Salary

Starting Final
Dates of Employment to
Job Title
Supervisor
Reason for Leaving

Work Performed
Employer
Employer
Address
City, State, Zip / /

Telephone Number(s)

 ( )

( )

Hourly Rate/Salary

Starting Final
Dates of Employment to
Job Title
Supervisor
Reason for Leaving

Work Performed
Employer
Employer
Address
City, State, Zip / /

Telephone Number(s)

 ( )

( )

Hourly Rate/Salary

Starting Final
Dates of Employment to
Job Title
Supervisor
Reason for Leaving

Work Performed

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

Summarize special job-related skills and qualifications acquired from employment or other experience.
5.Specialized Skills

Check Skills/Equipment Operated

CRT
Fax
PC
Lotus 1-2-3
Calculator
PBX System
Typewriter
WordPerfect
Production/Mobile Machinery (list):

Other (list):

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

Note to Applicants: 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 description of the activities involved in such a job or occupation is attached.

 Yes No
6. References
Reference 1
Name
Address
City, State, Zip ,
Phone Number ( )
Years Known
Reference 2
Name
Address
City, State, Zip ,
Phone Number ( )
Years Known
Reference 3
Name
Address
City, State, Zip ,
Phone Number ( )
Years Known
7. Spam Protection
Please retype this security word: zippo
8. Applicant’s Statement

I certify that answers given herein are true and complete to the best of my knowledge.

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, and employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is 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.

By submitting this application, I authorize all persons and companies named above to release information pertaining to my employment history and hereby release all parties from liability for damage for providing this information.