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Personal Information

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 Resource Department.

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Phone *

Alternate Phone

Social Security *

Email Address *

Position Applying For *

Referral Source *

Have you been employed here before *

Yes

No

If yes, please provide dates & position

Are you legally authorized to work in the United States? *

Yes

No

Have you ever been convicted of a felony? *

Yes

No

If yes, please explain.

What is your desired salary *

Driver license state *

Drivers license number - driving may be required in the position applying for

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.) *

Answering "yes" to either of the following questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, 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

Availability

Date available to begin *

Days Available *

Shift preference: *

1st

2nd

3rd

Any

Employment History

Starting with your most recent employer, please provide the following information.

Employer 1

Employer

Phone

Address

City, State

Start Date +

End Date +

Present

Job Title

$

Supervisor/Manager

Reason for Leaving

May we contact?

Phone Number

Summarize the type of work performed & job responsibilities

Employer 2

Employer

Phone

Address

City, State

Start Date +

End Date +

Present

Job Title

$

Supervisor/Manager

Reason for Leaving

May we contact?

Phone Number

Summarize the type of work performed & job responsibilities

Employer 3

Employer

Phone

Address

City, State

Start Date +

End Date +

Present

Job Title

$

Supervisor/Manager

Reason for Leaving

May we contact?

Phone Number

Summarize the type of work performed & job responsibilities

Educational Background

Last school attended (include city & state) *

GPA/Class rank

*

Diploma

GED

Degree

Certificate

Years Completed *

Major/Minor *

Previous school (include city & state)

GPA/Class rank

Diploma

GED

Degree

Certificate

Years Completed

Major/Minor

Previous school (include city & state)

GPA/Class rank

Diploma

GED

Degree

Certificate

Years Completed

Major/Minor

Additional Skills

Summarize any additional skills, training, computer knowledge, licenses and/or certificates that may assist you in performing the position for which you are applying.

References

Please send the following link to at least 3 references. These can include business/work references, school or personal references that are not related to you and not previous supervisors. References must be submitted before an interview is granted.

https://fs29.formsite.com/TxNi4G/3gowwphrwy/index.html

Please submit a copy of your resume.

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 non-defamatory information, in a lawful manner, int he 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 remain 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 reserces the same right to terminate my 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 authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

This company does not tolerate unlawful discrimination in its emplyment 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. 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 respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate 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 * +