General Information
	* First Name:   Middle Name:   * Last Name:   Position Desired:   Social Security Number:   - - Address 1:   Address 2:   City:   State:   Zip:   Phone 1:   Phone 2:   Email:   If you are under 18, and it is required, can you furnish a work permit?   -Select- Yes No over 18 If no, please explain:   Have you ever been employed here before?:   -Select- Yes No If yes, please give dates and positions:   * Are you legally eligible for employment in this country?   -Select- Yes No Date available to work:   * Desired Salary range: $ Type of employment desired:   -Select- Full-time Part-time Temporary Are you able to meet the attendance requirements of the position?   -Select- Yes No *Have you ever plead "guilty" or "no contest" to a criminal violation, been convicted of a criminal violation, or had adjudication of guilt withheld with respect to a criminal violation? (Failure to disclose the requested information will automatically result in your application being denied further consideration.)   -Select- Yes No If yes, please provide dates and details: Answering "yes" to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.   *Have you ever been terminated or asked to leave a position?   -Select- Yes No If yes, please explain:   * required fields

Employment History
	Employer 1 Employer:   Starting Job Title:   Ending Job Title:   Dates Employed:   Phone #:   Address:   City:   State:   (choose) AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:   Immediate Supervisor:   Summary of work performed:   Contact for reference?   Yes No Hourly rate or salary:   Reason for leaving:   Employer 2 Employer:   Starting Job Title:   Ending Job Title:   Dates Employed:   Phone #:   Address:   City:   State:   (choose) AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:   Immediate Supervisor:   Summary or work performed:   Contact for reference?   Yes No Hourly rate or salary:   Reason for leaving:   Employer 3 Employer:   Starting Job Title:   Ending Job Title:   Dates Employed:   Phone #:   Address:   City:   State:   (choose) AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:   Immediate Supervisor:   Summary or work performed:   Contact for reference?   Yes No Hourly rate or salary:   Reason for leaving:   Employer 4 Employer:   Starting Job Title:   Ending Job Title:   Dates Employed:   Phone #:   Address:   City:   State:   (choose) AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:   Immediate Supervisor:   Summary or work performed:   Contact for reference?   Yes No Hourly rate or salary:   Reason for leaving:

Skills and Qualifications
	Summarize any training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying: Note: Do NOT copy/paste or cut/paste from other word processing programs!   Enter your skills here.

Educational Background
	High School:   Years completed:   Graduate:   -Select- Yes No Course of Study:   College:   Years completed:   Graduate:   -Select- Yes No Course of Study:   Major:   Degree:   Other:   Years completed:   Graduate:   -Select- Yes No Course of Study:

References
	Name:   Phone #:   Years Known:   Name:   Phone #:   Years Known:   Name:   Phone #:   Years Known:

How did you hear about us?
	How did you hear about us?   -Select- Employee Referral Newspaper Ad Internet recruiting site Radio Other Name of employee referred by:

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. 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) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered. I expressly authorize, without reservation, the employer, its representatives, employees 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 such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a 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 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 cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and 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 authority to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard.

*  I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

* required fields