Date of Birth (MM/DD/YYYY)
Used for Background Check
Do you have a VALID Driver's License
Driver's License Number & State Issued
Last 4 of your Social Security Number
1. GENERAL INFORMATION
Position Interested In
Hourly Rate Expecting
Date you can start (MM/DD/YYYY)
Are you able to perform the essential job functions of the position for which you are applying with or without reasonable accomodation?
Have you been convicted of any felonies other than minor traffic violations during the past seven years? *
A criminal record or a conviction will not automatically bar employment, but will be considered only as it reasonably relates to your fitness to perform in the position for which you are applying.
2. EDUCATION & TRAINING
You may wish to list significant experience, interests & accomplishments gained while working as a volunteer or as a hobbyist that may be useful in the position (s) you are seeking. Names or organizations designating religion, race, etc. need not be mentioned.
4. PRESENT OF MOST RECENT EMPLOYER
5. EMPLOYMENT HISTORY
DO NOT SIGN UNTIL YOU HAVE READ, UNDERSTAND, AND ACCEPT THE FOREGOING APPLICANT STATEMENT!
I certify that the information contained in this application is correct to the best of my knowledge
and understand that any misstatement or omission of information may result in denial of employment
or discharge. I authorize the references listed above to give you any and all information concerning
my previous employment and any pertinent information they may have, personal or otherwise, and
release all parties from all liability for any damage that may result from furnishing same to you.
Applicant Statement * I certify that all of the information I have provided in order to apply for and
secure work with the employer is true, complete and correct.
* I understand that the employer does not unlawfully discriminate in employment and no question on
this application is used for the purpose of limiting or excusing any applicant from consideration
for employment on a basis prohibited by applicable local, state or federal law.
* I expressly authorize, without reservation, the employer, its representatives, employees or agents
to contact and obtain information from all references, 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 such information in the employment process and all other persons, corporations
or organizations for furnishing such information about me.order t o apply for and secure work with
the employer is true, complete and correct.
* I understand that this application remains current for 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 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 without
prior notice, and the employer reserves the same rights to terminate my employment at any time, with
our without cause and without prior notice, except as may be required by law. This application does
not constitute an agreement or contract for employment for any specific period or defined duration.
* 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) cancel further consideration of this
application, or (ii) immediately discharge me from the employer’s service whenever it is discovered.
* I also understand that if I am hired, I will be required to provide proof of identity and legal
authority to work in the United States and that federal immigration laws require me to complete an
I-9 Form in this regard.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant