Application Form

    ALL POTENTIAL EMPLOYEES ARE EVALUATED WITHOUT REGARD TO RACE, COLOR, RELIGION, AND GENDER, NATIONAL ORIGIN, AGE, MARITAL OR VETERAN STATUS, THE PRESENCE OF A NON-JOB RELATED HANDICAP OR ANY OTHER LEGALLY PROTECTED STATUS.

    APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS

    Date
    Name
    Address
    Best phone number to reach you on
    Additional Phone
    Social Security Number
    Date of Birth
    Please check one: Full timePart timeFirst availableDaysEvenings
    Last place of employment
    Currently employed here? YesNo
    Phone Number
    Supervisor Name
    What is your means of transportation to work?
    Are you a US citizen; or are you otherwise authorized to work in the US without any restriction? YesNo
    Have you ever been convicted of a felony? YesNo
    Have you ever been involuntarily terminated or asked to resign from any position of employment? YesNo
    Do you have any physical conditions that may limit your ability to perform the job you applied for? YesNo
    Does standing on your feet, or lifting above your head cause you any difficulties? YesNo
    If yes, Please Explain
    Please list any languages you can speak
    Please list two references other than relatives or former employers.
    Name
    Phone
    Name
    Phone

    I certify that answers given herein are true and complete to the best of my knowledge.

    I authorize investigation of all statements contained in this application for employment as may be necessary for arriving at an employment decision.

    This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at this time.

    I hereby understand and acknowledge that unless otherwise defined by applicable law, any employment relationship with this organization is of an “at-will” nature, which means that the employee may resign at any time and the employer may discharge an employee at any time with or without cause. It is further understood that this “at-will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

    In the event of employment, I understand that false or misleading information given in my application or interview may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

    Signature
    Date

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