APPLICATION FOR EMPLOYMENT

Blank Form (#3)

APPLICATION FOR EMPLOYMENT

Fields marked with an * are required

Date

Please Answer All Questions. Resumes are not a substitute for a Completed Application. We are an equal opportunity employer. Applicants are considered for positions without regard to veteran/military status, race, color, religion, sex/gender, national origin, ancestry, age, disability, genetic information, pregnancy (including childbirth, lactation, and related medical conditions), alienage or citizenship status, sexual orientation, gender identity or expression, or any other category protected by applicable federal, state, or local laws.

THIS APPLICATION FOR EMPLOYMENT IS NOT AN EMPLOYMENT CONTRACT.

The Company provides reasonable accommodations to applicants with disabilities to assist in the hiring process, as required by applicable federal, state, and local law. Individuals can request an accommodation to complete this application or to participate in the interview process by contacting Human Resources.

Applicant Name

Position Applied For

Telephone Number

Alternate/Cellular Telephone Number

Address

Present Address

City

State

ZIP

Email Address (optional)

You must be 21 to apply. Are you at least 21 years of age? *

Yes

Type of employment desired?

Full-time

Part-time

Are you willing to work overtime?

Yes

Date on which you can start work, if hired:

If hired, can you provide proof that you are legally eligible for employment in the U.S.?

Yes

N/A

(Pursuant to the Immigration Reform and Control Act of 1986, all applicants (U.S. and non-U.S.) who are offered employment must produce documents establishing their identity and authorization for U.S. work no later than seventy-two (72) business hours after employment begins. All new hires will be required to verify their employment authorization under oath by signing INS Form 1-9 upon commencing employment.)

Have you previously applied for employment with this Company?

Yes

If Yes, when and where did you apply?

Do you have any commitments to any other employer which could affect your employment with this Company if hired (for example, an employment agreement, a non-competition, or non-solicitation agreement, etc.)?

Yes

If yes, please explain and provide a copy:

Education

High School

School Name and Location (Address, City, State)

Course of Study or Major

Graduate/GED?

Yes

# of Years Completed

Honors Received

Graduate/ Professional

School Name and Location (Address, City, State)

Course of Study or Major

Graduate/GED?

Yes

# of Years Completed

Honors Received

Trade or Correspondence

School Name and Location (Address, City, State)

Course of Study or Major

Graduate/GED?

Yes

# of Years Completed

Honors Received

WORK EXPERIENCE

Please list the names of your present and/or previous employers in chronological order with present or most recent employer listed first. Provide information for at least the most recent ten (10) year period. Attach additional sheets if needed. If self-employed, supply firm name and business references. You may include any verifiable work performed on a volunteer basis or internships. You may describe any training or work experience received in any U.S. military service. Your failure to completely respond to each inquiry may disqualify you for consideration from employment. Do not answer "see resume."

Employer

Name

Address

Type of Business

Telephone

Dates Employed From

Job Title

Duties

Supervisor's Name

May we contact?

Yes

If No, why not?

What will this employer say was the reason your employment terminated?

Reason for Leaving?

Were you ever disciplined? If so, for what?

If you resigned, how much notice did you give? If none, explain.

Employer

Name

Address

Type of Business

Telephone

Dates Employed From

Job Title

Duties

Supervisor's Name

May we contact?

Yes

If No, why not?

Reason for Leaving?

What will this employer say was the reason your employment terminated?

Were you ever disciplined? If so, for what?

If you resigned, how much notice did you give? If none, explain.

Have you ever been terminated or asked to resign from any job?

If Yes, how many times?

Have you ever been given the choice to resign rather than be terminated?

Yes

If Yes, how many times?

Yes

If you answered Yes to any of the above three questions, please explain the circumstances of each occasion.

Briefly describe any special skills, training, or experience you possess relevant to the position for which you are applying:

List any professional or occupational registration, licensure or certification you currently hold which is relevant to the position for which you are applying and/or indicate whether you have ever had any related professional registration, license, or certification suspended, revoked or terminated.

To the extent required by applicable law, the Company maintains a smoke-free workplace.

Applicant Signature

Date