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APPLICATION FOR EMPLOYMENT
Please Answer All Questions. Résumés Are Not A Substitute For A Completed Application.


We are an equal opportunity employer. Applicants are considered for positions without regard to race, religion, sex, national origin, age, disability, or any other category protected by applicable federal, state, or local laws.


THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE.

Your Information:
Position Applied For: A value is required. Full Name A value is required.
Telephone Number A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.
Area Code + Phone Number ( 000-000-0000 )		 Alternate or Cellular A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.
Area Code + Phone Number ( 000-000-0000 )
Present Address A value is required.
Street Address, City, ST, Zip		 How long have you lived there? Years A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters. Months A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.
Previous Address
Street Address, City, ST, Zip		 How long have you lived there? Years Months
Desired Salary/Hourly A value is required. eMail Invalid format.
Are you under 18? If under the age of 18, can you produce the necessary work certificate at the time of employment? YES NO
 
Type of employment desired? Full-time Part-time (Specify Hours)
Are you willing to work overtime? YES NO : Date on which you can start work if hired
Have you previously applied for employment with this Company? YES NO
If Yes, when and where did you apply?
Have you ever been employed by this Company? YES NO
If Yes, provide dates of employment, location, and reason for separation from employment.

 
INSTRUCTIONS FOR ANSWERING THE NEXT TWO QUESTIONS

1. All applicants: Do not include convictions that were sealed, eradicated, erased, annulled by a court, or expunged, or convictions that resulted in referral to a diversion program.

2. Arizona, Colorado, District of Columbia, Illinois, Kansas, Minnesota, Missouri, Montana, Nevada, Rhode Island, South Carolina, and Utah applicants: Do not respond to the second question regarding arrests.

3. California applicants: Do not include misdemeanor marijuana-related convictions that are more than two (2) years old or
misdemeanor convictions for which probation was successfully completed or otherwise discharged and the case was judicially dismissed.

4. Connecticut applicants: You are not required to disclose the existence of any arrest, criminal charge, or conviction, the records of which have been erased. Criminal records subject to erasure are records pertaining to a finding of delinquency or the fact that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled (not prosecuted), a criminal charge for which the person was found not guilty, or a conviction for which the offender received an absolute pardon. Any person whose criminal records have been erased is deemed to have never been arrested within the meaning of the law as it applies to the particular proceedings that have been erased, and may so swear under oath.

5. District of Columbia and Washington applicants: Limit any response to the past ten (10) years.

6. Hawaii applicants: Do not answer the following two questions.

7. Indiana applicants: Regarding arrests limit your response to pending charges for felonies and class A misdemeanors that are less than one (1) year old.

8. Massachusetts applicants: Limit any response regarding misdemeanor convictions to the last five (5) years and to those which were not a first offense for drunkenness, simple assault, speeding, a minor traffic violation or disturbing the peace. Applicants with a sealed record on file with the Massachusetts Commissioner of Probation may answer “No Record” with respect to: 1) all inquiries relating to prior convictions or arrests; 2) misdemeanor convictions older than five (5) years; and 3) first time convictions for simple assault, drunkenness, speeding, minor traffic violations or disturbing the peace.

9. Michigan applicants: Regarding arrests, limit your response to felony arrests awaiting conviction or dismissal.

10. New York applicants: All pending arrests or criminal accusations must be disclosed. You are not required to disclose arrests or criminal accusations that resulted in criminal actions or proceedings which were terminated in your favor. Do not disclose criminal actions or proceedings that were sealed or classified as youthful offender adjudications. An ex-offender who is denied employment may, upon written request, receive a statement of the reason(s) for denial within thirty (30) days of the applicant’s request for such information.

11. North Dakota and Oregon applicants: Regarding arrests, limit your response to pending charges that are less than one (1) year old.

12. Utah applicants: Limit any response to felony convictions only. Do not respond to the second question regarding arrests.
 
Have you ever plead guilty or no contest to, or been convicted of any criminal offense other than the applicable exceptions listed above?
YES NO
Have you ever been arrested for any matters for which you currently are out on bail or on your own recognizance pending trial?
YES NO
CRIMINAL OFFENSES ONLY: If you answered Yes, to either of the above two questions, please provide the date(s) and explain in
accordance with the above instructions so that individual circumstances can be considered.
 
Criminal convictions or arrests will not automatically disqualify an applicant from a particular job. The Company will consider the nature of the crime, its seriousness, the substantial relation to the position’s functions and qualifications, the number of occurrences, the applicant’s age at the time of the crime, the time elapsed since the crime, the applicant’s entire work and educational history, employment references and recommendations, and the business necessity of any exclusion when required by law.
 
Have you ever initiated an act of violence in the workplace? YES NO
If Yes, please provide the date(s) and explain so that individual circumstances can be considered. (A “Yes” answer will not necessarily
disqualify you from employment.)
 
List all special technical skills that you feel qualify you for the job for which you are applying (For example., computer
programming/language, software, equipment operation, special tools or machines, etc.)
 
EDUCATION
Education
School Name and Location
(Address, City, State)
Course of Study
Graduate?
# of Years Completed
Degree/Major
           
High School
YES NO
College
YES NO
Bus./Tech./Trade
or Post College
YES NO
 
Honors Received
 
If applicable, list below any other names by which you have been known which may be necessary to allow us to confirm your work and
educational record. For example, change of name, use of an assumed name, nickname, etc.
 
 
WORK EXPERIENCE
Please list the names of your present and/or previous employers in chronological order with present or last employer listed first. Account for all periods of time including any period of unemployment. If self-employed, supply firm name and business references. You may include any verifiable work performed on a volunteer basis, internships, or military service. Your failure to completely respond to each inquiry may disqualify you for consideration from employment.
 
EMPLOYMENT HISTORY
Employer
    

Name

Address

Type of Business

Telephone
Dates Employed
From To
Example: 01/01/2009

Job Title
Duties

Supervisor’s Name		 May we contact? YES NO If No, why not?

Wages Start
Final		 Reason for Leaving
What will this employer say was the reason your employment terminated?
How much notice did you give when resigning? If none, explain.
 
Employer
    

Name

Address

Type of Business

Telephone
Dates Employed
From To
Example: 01/01/2009

Job Title
Duties

Supervisor’s Name		 May we contact? YES NO If No, why not?

Wages Start
Final		 Reason for Leaving
What will this employer say was the reason your employment terminated?
How much notice did you give when resigning? If none, explain.
 
Employer
    

Name

Address

Type of Business

Telephone
Dates Employed
From To
Example: 01/01/2009

Job Title
Duties

Supervisor’s Name		 May we contact? YES NO If No, why not?

Wages Start
Final		 Reason for Leaving
What will this employer say was the reason your employment terminated?
How much notice did you give when resigning? If none, explain.
 
 
Please explain fully all gaps in your employment history in excess of one month.
 
Have you ever been terminated or asked to resign from any job? YES NO : If Yes, how many times?
Has your employment ever been terminated by mutual agreement? YES NO : If Yes, how many times?
Have you ever been given the choice to resign rather than be terminated? YES NO : If Yes, how many times?
 
If you answered Yes to any of the above three questions, please explain the circumstances of each occasion.
 
REFERENCES
Please list the names of additional work-related references we may contact. Individuals with no prior work experience may list school or
volunteer-related references.
 
NAME
POSITION
COMPANY
WORK RELATIONSHIP
(i.e., supervisor, co-worker)
TELEPHONE
         
 
 
Please list the names of personal references (not previous employers or relatives) who know you well that we may contact.
NAME
OCCUPATION
ADDRESS
TELEPHONE
NUMBER OF
YEARS KNOWN
         
 
APPLICANT CERTIFICATION
 
I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver’s license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside.

I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that all employees of the location, pursuant to the Company’s policy and federal, state, and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs. If employed, I understand that the taking of alcohol and/or drug tests is a condition of continual employment and I agree to undergo alcohol and drug testing consistent with the Company’s policies and applicable federal, state, and local law.

If employed by the Company, I understand and agree that the Company, to the extent permitted by federal, state, and local law, may exercise its right, without prior warning or notice, to conduct investigations of property (including, but not limited to, files, lockers, desks, vehicles, and computers) and, in certain circumstances, my personal property.

I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to
sign a confidentiality, restrictive covenant, and/or conflict of interest statement, as well as an agreement to arbitrate.

I certify that all the information on this application, my résumé, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.

THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT—EXPRESS OR IMPLIED—WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY.

IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL.

I authorize the Company or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I am seeking and to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation.

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information.

If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Company. I also understand this Company employs only individuals who are legally eligible to work in the United States.

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY. I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE.

 
 
Applicant Signature
 
Digital Signature
A value is required.
Please type your name in the box (in lieu of a signed signature).
A value is required.Minimum number of characters not met.Exceeded maximum number of characters.Invalid format.
Date ( mm / dd / yyyy )
Please use slash marks /
 
If the applicant is a minor, the foregoing release and consent must be signed by the applicant’s parent or legal guardian. Signature by the applicant’s parent or legal guardian constitutes acknowledgement by the applicant and the parent or legal guardian that the Company, to the extent permitted by federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate test results to Company personnel who need to know, the applicant, and the applicant’s legal guardian.
 
 

Parent/Legal Guardian
Witness

Date
Date
Please type your name in the box (in lieu of a signed signature).
 
 
       


THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE.

“I agree to the above” Please make a selection.

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