Application Application for Employment The Company is an Equal Employement Opportunity Employer. Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, marital status, national origin, age, physical or mental disability, medical condition, sexual orientation, or any other consideration made unlawful by applicable federal, state, or local laws.PersonalName* First Middle Last Other name(s) under which you have been previously employed Best Contact Phone*Best Contact Email* Permanent Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you willing to work overtime, or a flexible work schedule?* Yes No If hired, can you provide proof of identity and legal authorization to work in the U.S.?* Yes No After carefully reviewing the job description and physical requirements of the job for which you are applying, are you able to perform the essential functions of the job, with or without reasonable accommodation?* Yes No Type of employment you are seeking* Full time Part time Name of referral source Employment InterestsPosition desired or area of interest* Second choice Date Available* Salary Expected Education / U.S. Military ServiceHigh SchoolName of High School High School Diploma Earned HSD GED High School Location City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State CollegeName of College or University Degree College Location City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Military ServiceName of Military Base Military Base Location City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are you multi-lingual? Yes No What languages? What level of proficiency? Employment HistoryReferences may be requested at a later point. Give employment record as completely as possible. Listing most recent employer first, show unemployed or self-employed periods and indicate dates and comment on each period. Include part time or summer work. Add additional past employers under the first by clicking 'Add Additional Employer'.Company Name Type of Business City/State City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Dates Employed (Month/Year)From To Job Title Supervisor's Name and Title TelephoneDescription of dutiesReason for leaving? May we contact this employer? Yes No Additional Employment History Company Name City/State Edit Delete There are no Additional Employers. Add Additional Employer Maximum number of additional employers reached. AcknowledgementThis application is not complete until signed, and all statements below have been read and initialed.Initials* Accuracy of Information: I certify that all the information furnished on this application and during the application process is true, complete and correct to the best of my knowledge. I understand that any misrepresentation or omission of facts called for by this application, whether material or not, will result in refusal to hire, or, if hired, will result in my dismissal at any time regardless of when the false answers or omissions are discovered.Initials* Reference Checks: I understand that all statements contained in this application may be investigated by the Company. I authorize the Company to secure information about my experience from former employers, educational institutions and agencies, and for those parties to provide information concerning my experience to the Company. I release all parties from any liability arising from the disclosure or use of the information by any person or party.Initials* Background Checks: I agree to complete the requisite authorization forms necessary for the Company or a third party hired by the Company to conduct a background investigation, including a criminal history check and a Department of Motor Vehicles record check. I understand that any offer of employment I may receive is contingent upon successful completion of any reference and background checks.Initials* At–Will Employment: I recognize that this employment application is not an offer of employment. I further agree that if I am hired by the Company, I will be an at-will employee, which means that either the Company or I may terminate the employment relationship at any time with or without cause or notice. I agree that no written materials or verbal statements by the Company will constitute an express or implied contract of continued employment or employment for a specific or definite time period and that, if I am hired, no representative of the Company except for the President of the Company has authority to enter into any agreement with me contrary to at-will employment. Any such agreement must be in writing signed by the President of the Company and me.Initials* Physical Examinations: If I am offered employment, I understand and agree that I may be required to undergo a physical examination and that my offer of employment may be conditioned and that my offer of employment may be conditioned upon the results of that examination. I agree to authorize the release of the results obtained from such physical examinations to the Company.Initials* Drug and Alcohol Testing: I agree to submit to legally permissible drug and/or alcohol testing upon request by the Company, and that failure to do so may result in my application being withdrawn from consideration or my employment being terminated. I recognize that the results of these tests may be used to determine my employment or continued employment. I understand and agree that if employed by the Company, storage areas provided for me (locker, desk, etc.) are open to investigation by the Company without prior notice to me.Initials* Confidentiality: Except as required in the performance of my duties, I understand and agree that I will not at any time during or after my employment use, disclose or disseminate any confidential information or any other information of a secret, proprietary or generally undisclosed nature relating to the Company, or its products, customers, employees, plans, or procedures. I agree to deliver to the Company any and all copies of confidential information, or other Company property, upon termination of the employment relationship or at any time upon the Company’s request. I also agree not to solicit employees of the Company either during or for one year after employment to leave the Company and commence work with another employer.If you have any questions regarding this acknowledgement, please ask a company representative before signing. My signature below certifies that I agree to be bound by the terms and conditions stated in this application, which contains the entire understanding between the Company and me concerning the topics addressed herein, and supersedes any prior inconsistent understandings between the Company and me on these issues.Signature Please sign by typing your full name.Date MM slash DD slash YYYY This application will only be considered for 30 days. If you have not been hired within 30 days of filling out this application and you wish to continue to be considered for employment, you must complete another application. Δ
