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APPLICANT NOTE

This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination because of sex, marital status, race, color, age, creed, national origin, sexual orientations, military reserve membership, ancestry, religion, height, weight, use of a guide or support animal because of blindness, deafness or physical handicap, or the presence of disabilities. A felony conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.

CONTACT INFORMATION: Step 1 of 8

Current Address

At current address longer than 5 years?

POSITION INFO: Step 2 of 8

For which position are you applying?

What date can you start?

What Wage / Salary do you expect?

What category would you prefer?

For which schedules are you available?

NOTE: Do not fill out any part of this section you believe to be non-job related.

If the job requires, do you have the appropriate valid driver’s license?

Have you had any moving violations?

Please list any other skills, licenses or certificates that may be job-related or that you feel would be of value to this job or company.

Have you been given a job description or had the essential functions of the job explained to you?

Do you understand these essential functions?

Can you perform the essential functions of this job with or without reasonable accommodation?

SECURITY: Step 3 of 8

List languages in which you are fluent:

List states and counties of residence for the past 7 years:

Have you been convicted of a crime in the past seven years? If so, please describe in the boxes below. (Conviction will not necessarily be a bar to employment. (In accordance with company policy and applicable state and federal laws, factors such as age at time of the offense, remoteness of the offense, time since last conviction, nature of the job sought and rehabilitation effort will be reviewed.)

Comments

PREVIOUS EMPLOYERS: Step 4 of 8

Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical. Ask for a phone book or call information if you need. FOR EMPLOYERS OUTSIDE THE U.S., A CURRENT FAX NUMBER IS MANDATORY.

MOST RECENT EMPLOYER

Are you currently working for this employer?

Date Employed From

Date Employed To

Job Title

Supervisor’s Name

Duties

Salary

Reason for Leaving

SECOND MOST RECENT EMPLOYER

Date Employed From

Date Employed To

Job Title

Supervisor’s Name

Duties

Salary

Reason for Leaving

REFERENCES: Step 5 of 8

Include only individuals familiar with your work ability. Do not include relatives.

EDUCATION: Step 6 of 8

Note: Do not fill out any part of this section you believe to be non job-related.

Please select the highest grade completed.

If your school records are under a different name than listed on page 1, please enter that name:

HIGH SCHOOL

Name

City/State

Did you graduate?

Degree

COLLEGE

Name

City/State

Did you graduate?

Degree

OTHER

Name

City/State

Did you graduate?

Degree

Please list areas of work you are skilled in that you feel would apply to the position you are applying for. Please indicate your level of proficiency on a scale of 1-5 with 1 being the lowest and 5 being the highest.

RESUME & COVER LETTER: Step 7 of 8

Resume

Cover Letter

CERTIFICATION & RELEASE: Step 8 of 8

I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejections of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information. I authorize all former employers, persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

Signature

Date

*Required Fields