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PERSONAL DATA

Desired Salary:

Name*:

First

Middle

Last

Email*:

Street Address:

City:

State:

Zip Code:

Home Telephone:

Cell Phone:

POSITION APPLIED FOR:

DATE:

If you are under 18 years of age, please specify your age:
(This information will be used only for child labor law purposes).


Are there any days, shifts or hours you will not work?*: YesNo

If yes, please explain:

Are you available for out of town work?*: YesNo

Will you work overtime, if required?*: YesNo

Do you have any restrictions on hours?: YesNo

Do you have reliable transportation?: YesNo


*Note: It is not necessary for you to identify unavailability for work because of religious observance or practice or any other protected classification. Subsequent to any job offer, we will consider whether a reasonable accommodation can be made.

How did you learn of our Company?:

Have you ever applied or worked at our Company before?: YesNo

If yes, provide dates:

Are you legally authorized to work in the United States?: YesNo


(We are an E-Verify employer and must comply with Federal laws set forth by the U.S. Department of Homeland Security and Social Security Administration to confirm employment eligibility Therefore, you MUST provide proof you are legally authorized to work in the United States.)


Will you now or in the future require sponsorship for employment visa status (e.g.,H-1B visa status)?: YesNo

Have you ever been convicted of a felony? (if yes please explain in detail if no description is given application WILL NOT be reviewed):



DRIVING RECORD

(Answer ONLY if driving is a requirement of the job for which you are applying).

Do you have a valid driver’s license?: YesNo
State:
License No:

Have you had any tickets?: YesNo

If yes, please explain:



EDUCATION

Describe any educational degrees, skills, training or experience you believe are relevant to the job applied for:

High School

Graduated? : YesNo

If no, Degree Credits Earned:

Type of Degree Received or Expected:

Major:

Minor:

Grade Point/ Overall GPA:

College or University

Graduated? : YesNo

If no, Degree Credits Earned:

Type of Degree Received or Expected:

Major:

Minor:

Grade Point/ Overall GPA:

Technical/GED

Graduated? : YesNo

If no, Degree Credits Earned:

Type of Degree Received or Expected:

Major:

Minor:

Grade Point/ Overall GPA:

Licenses/ Certification/Other

Graduated? : YesNo

If no, Degree Credits Earned:

Type of Degree Received or Expected:

Major:

Minor:

Grade Point/ Overall GPA:



EMPLOYMENT HISTORY:

Please complete for all full-time or part-time employment beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis. All applicants should start with their most recent job, include military assignments and voluntary employment and provide ten (10) years of history. (A separate sheet may be attached.) You must explain any gaps in your employment history.

Company Name:

Telephone:

Address:

Name of Supervisor:

May we contact: YesNo

Dates Employed: From:

To:

Rate of Pay: Start:

Last:

State job titles and describe job duties:

Reason for leaving:



Company Name:

Telephone:

Address:

Name of Supervisor:

May we contact: YesNo

Dates Employed: From:

To:

Rate of Pay: Start:

Last:

State job titles and describe job duties:

Reason for leaving:



Company Name:

Telephone:

Address:

Name of Supervisor:

May we contact: YesNo

Dates Employed: From:

To:

Rate of Pay: Start:

Last:

State job titles and describe job duties:

Reason for leaving:



Company Name:

Telephone:

Address:

Name of Supervisor:

May we contact: YesNo

Dates Employed: From:

To:

Rate of Pay: Start:

Last:

State job titles and describe job duties:

Reason for leaving:



Have you ever been discharged or asked to resign from employment?: YesNo

If yes, explain:

Did you receive any discipline in your last 12 months of active employment with your previous employer?: YesNo

If yes, explain:

Were you given a performance evaluation within the last 12 months of active employment?: YesNo

If yes, what was the range of scores used and what was your score?:



PROFESSIONAL REFERENCES

(Please list three individuals unrelated to you with whom you have worked who know your qualifications for this position.)

Name:

ADDRESS:

Phone:

Relationship:



Name:

ADDRESS:

Phone:

Relationship:



Name:

ADDRESS:

Phone:

Relationship:



Name:

ADDRESS:

Phone:

Relationship:



MILITARY

(Complete only if you served in the military.)

Branch of Service:

Number of Years /Months of Service:

Rank at Discharge:

Date of Discharge:

Describe any military skills, training or experience you believe are relevant to the job you applied for:

Voluntary information; not required



Ethnicity

African AmericanCaucasianEskimoAsianNative AmericanHispanic

Gender

MaleFemale



APPLICANT’S ACKNOWLEDGMENT

[applicants_acknowledgment]

Signature:

Date:



DISCLOSURE/RELEASE/AUTHORIZATION FORM

[disclosur_form]

Applicant's Signature:

Print Name:

Today’s Date:

Other Names Used:

Social Security Number:

Date of Birth:

Driver's License #

State:

Current Address:

City:

State:

Zip:

Previous Address:

City:

State:

Zip: