APPLICATION FOR EMPLOYMENT

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

    Name:

    Address:

    Telephone # :
    Cellular/Other Phone # :
    Email Address :
    Position(s) applied for :
    Date of application :
    Referral Source (Please check the appropriate category and list the source.)
    If necessary. best time to call you is
    May we contact you at work?
    YesNo
    If yes, work number and best time to call:

    If you are under 18 and it is required,

    Can you furnish a work permit?
    If no. please explain:
    Have you submitted an application here before?
    If yes, give date(s) and position(s):

    Have you ever been employed here before?

    If yes, give dates:
    From
    To:
    Is this application a request for reemployment following an extended militrary leave of absence from this company?
    Are you legally eligible for employment in this Country?
    Date available for work:
    What is your desired salary range or hourly rate of pay?
    $
    Per
    Type of employment desired:
    Will you relocate if job requires it?
    Will you travel if job requires it?
    If they have been explained to you are you able to meet the attendance requirements of the position?
    Will you work overtime if required?

    If no, please explain:

    Are you able to perform the “”essential functions”” of the job for which you are applying (with or without reasonable accommodation)?

    This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability. particular accommodation. or whether accommodation is necessary. These issues may be addressed at a later stage to the extent Permitted by law

    Driver’s license number required if driving may be required in the job for which you are applying:
    State :
    Have you ever been bonded?

    Answering “yes” to the following question does not constitute an automatic bar to employment. Factors such as date of offense. seriousness and nature of the isolation. rehabilitation and position applied for will be taken into account.

    Have you ever pleaded “guilty” or “no contest” to or been convicted of a crime?
    If yes, please provide date(s) and details
    Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might in any way. restrict your ability to work for our company?

    If yes. please explain

    AN EQUAL OPPORTUNITY EMPLOYER

    Employee History

    Start with your most employer, Provide the following information.

    Employer
    Telphone #
    Street Address
    City
    State
    Starting job title / final job title
    Immediate Supervisor and title(for most recent position field)
    May We Contact for Reference
    Why did you leave?
    Email :
    Dates of Employed

    /

    To :

    /

    Compensation (Starting)

    $

    Per

    Commission Bonus Other Compensation

    $

    Compensation (Final)

    $

    Per

    Commission Bonus Other Compensation

    $
    Summarized the type of work Performed and Job responsibilities
    What did you like the most about your Position
    What were the thing you liked the least about the Position
    Employer
    Telephone #
    Street Address
    City
    State
    Starting job title / final job title
    Immediate Supervisor and title(for most recent position field)
    May We Contact for Reference
    Why did you leave?
    Email :
    Dates of Employed

    /

    To :

    /

    Compensation (Starting)

    $

    Per

    Commission Bonus Other Compensation

    $

    Compensation (Final)

    $

    Per

    Commission Bonus Other Compensation

    $
    Summarized the type of work Performed and Job responsibilities
    What did you like the most about your Position
    What were the thing you liked the least about the Position
    Employer
    Telephone#
    Street Address
    City
    State
    Starting job title / final job title
    Immediate Supervisor and title(for most recent position field)
    May We Contact for Reference
    Why did you leave?
    Email :
    Dates of Employed

    /

    To :

    /

    Compensation (Starting)

    $

    Per

    Commission Bonus Other Compensation

    $

    Compensation (Final)

    $

    Per

    Commission Bonus Other Compensation

    $
    Summarized the type of work Performed and Job responsibilities
    What did you like the most about your Position
    What were the thing you liked the least about the Position
    Employer
    Telephone#
    Street Address
    City
    State
    Starting job title / final job title
    Immediate Supervisor and title(for most recent position field)
    May We Contact for Reference
    Why did you leave?
    Email :
    Dates of Employed

    /

    To :

    /

    Compensation (Starting)

    $

    Per

    Commission Bonus Other Compensation

    $

    Compensation (Final)

    $

    Commission Bonus Other Compensation

    $
    Summarized the type of work Performed and Job responsibilities
    What did you like the most about your Position
    What were the thing you liked the least about the Position
    Explain any gaps in your employment, other than those due to personal illness, injury or disability.
    Explain any gaps in your employment, other than those due to personal illness, injury or disability.
    If not addressed on previous page, have you ever been fired or asked resign from a job?
    If yes , Please Explain

    Skills and Qualifications

    Summarize any special training, skills , licenses and/or certificates that may assist you in performing the position for which you are applying:
    Computer Skills(check appropriate boxes, Include software titles and years of experience.)

    Educational Background

    Starting with your most recent school attended, provide the following

    School (Include City and State) Years Completed Completed GPA Class Rank Major/Minor

    References

    Lists names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three schools or personal references who are not related to you.

    Name title Relation to you Telephone E-mail Years Known

    Related Information

    To what job-related organizations (professional, trade, etc.) do you belong?

    Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, metal or physical disabilities, veteran/serve, National Guard or any other similarity protected status

    Organization Offices Held

    List special accomplishments, publications, awards, etc.

    Exclude information that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status
    In your current or previous job. have you ever written instructions or directions to he followed by employees or customers?
    If yes, please explain
    Is there any other job-related information you want us to know about you.

    Related Information

    I certify that all information I have provided in order to apply for and secure work with this employer is true. complete and correct.

    I expressly authorize. without reservation. the employer. its representatives. employees or agents to contact and obtain information from all references (personal and professional). employers. public agencies .. licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application. resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer. its agents. employees or representatives. for seeking. gathering and using truthful and nondefamatory infom1ation, in a lawful manner. in the employment process and all other persons. corporations or organizations for furnishing such information about me.

    I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

    I understand that this application remains current for only .30 days. At the conclusion of that time. if I have not heard from the employer and still wish to be considered for employment. it will be necessary for me to reapply and fill out a new application.

    If I am hired. I understand that I am free to resign at any time. with or without cause and with or without prior notice. and the employer reserves the same right to terminate m) employment at any time. With or without cause and with or without prior notice. except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

    I also understand that if I am hired. I will be required to provide proof of identity and legal authori1.ation to work in the United States and that federal immigration laws require me to complete anl-9 From in this regard. This organization participates in E-Verify.

    This company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state. or local law. This company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, age, disability or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

    I understand that any information provided by me that is found to be false, incomplete or misrepresented in any aspect will be sufficient cause to (i), eliminate me from further consideration for employment, or (ii) may result in my discharge from the employer’s service, whenever it is discovered.

    DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

    I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

    Signature of Applicant :
    Date