Application for Employment
An Equal Opportunity Employer

Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. All information given will be available only to persons who have a "need to know" or as required by law. This company will make reasonable accomodation in the application process, if needed.

Personal Information

Work Preference

Note: Please indicate conditions you prefer or would accept and other information by entering "yes" or "no" in every blank in the remainder of the sections on this page.

Availability For Work

Temporary or Short Term
Long Term
Night Shift

Yes     No

Yes     No

Present Employment

Yes     No


Yes     No
Yes     No

Yes     No

Prior Events

Yes     No
Yes     No

Yes     No

Education and Training

Grade and High School
Yes     No
6     7     8     9     10     11     12

College or University
A.A.     A.S.     B.A.     B.S.    

Other (Graduate, Trade School, Correspondence School, etc)
Yes     No

Record of Employment

Current / Most Recent Employer

Next Previous Employer

Next Previous Employer

List other positions and periods of unemployment*:

Certificate of Applicant

Read carefully before signing

All information provided by me is true and correct to the best of my knowledge. I understand any omissions or misrepresentations on this application may result in rejection, or if employed, may be cause for subsequent dismissal. I hereby authorize an former employer, person, firm or corporation listed herein including this company to answer any and all questions and agree to hold all persons harmless for giving any and all truthful information within their knowledge or records. I understand this is a preliminary application and not a contract to employ me. I understand and agree that any employment I may obtain is for no definite period of time. If employed, I agree to comply with all rules of the company as a condition of continued employment.

This Employment Application is used to notify me that the nature and scope of an investigation, if one is conducted, could include such general identification information as residence verification, and, as applicable, information concerning my employment, education, general reputation, character, personal characteristics, and habits, and that such information may be developed through personal interviews with third parties such as family members, neighbors, friends, associates, former employers, financial sources, and custodians of official records. Only job-related information developed from such a report will be considered in evaluating my employment application or continued employment. I hereby authorize these persons, companies, organizations or corporations to answer all questions or release any information regarding the items listed in this paragraph. I hereby release them from any liability and hold them harmless from any claim for releasing any truthful information within their knowledge and/or records.

I authorize the company to release to any person, firm, entity, or organization with which I may seek employment in the future, any truthful information concerning my work experience with the company. I hereby release and hold the company harmless from any claim for releasing any truthful information within its knowledge and/or records.

Qualified applicants receive equal consideration. No question is asked for the purpose of excluding any applicant due to race, creed, color, national origin, religion, age, disability, sex, etc. "An equal opportunity employer".

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