Employment Application

This application form is intended for use in evaluting your qualification for employment. This is not an employment contract. Please answer all appropriate questions completley and accuratley. 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 applications will recieve consideration with discrimination because of sex, marital status, race, color, age, creed, national origin, or presence of disabliities. 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 system may be required prior to employment. You will be required to complete a medical history form.

First Name

Middle Name

Last Name

Phone Number

Are you of 18 years or older?
Yes No

Current Address

Address

City

State

Zip

Previous Address

Address

City

State

Zip

Availability

For which position are you applying?

What date can you start?

What category would you prefer?
Full Time Part-time Temporary Labor Pool

Which schedule are you available?
Weekdays Weekends Evenings Overtime Student

Available for out-of-town work? Yes No

Please provide your availability if you're a student or if you have any additional information about your availability:

Job-Related Skills

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? Yes No

Name on license

Driver's License Number

Type

State of Issue

If you have a CDL, have you tested positive for a drug test in the last three years? Yes No

Have you had any moving violations? Yes No

Please describe

Have you been convicted of, or served time for a felony? Yes No

If so, please describe in the boxes below. (In accordance with company policy, this information will be reviewed for job relatedness and time since last convictions)

Incident

City/State

Charge

Most Recent Employer

Are you currently working for this employer? Yes No

If yes, may we contact? Yes No

Company Name

Address

City

State

Zip

Phone

Fax

Dates Employed

From

Duties

Job Title

Supervisor Name

Salary

Reason for Leaving

Education

Please select the highest grade completed

If your school records are under a different name than listed above, please enter that name

High School

Name

City/State

Degree

College

Name

City/State

Degree

Other

Name

City/State

Degree

I certify that I have read and understand the applicant note at the top of this page and that the answers given by me to the forgoing 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 for misrepresentations of fact call for the applicatino may result in rejection of my application or discharge at any time during my employment. I authorize all former employer, persons, school, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, school, companies, and law enforcement authorities from any liability for any damage whatever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If the company policy requeries, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.