It is our policy to comply with all applicable state and federal laws prohibiting discrimination in e mployment based on race, age, color, sex, religion, national origin, disability or other protected classifications. Please carefully read and answer all questions. You will not be considered for employment if you fail to completely answer all the questions on this application. You may attach a résumé, but all questions must be answered PERSONAL DATA Name (last, first, middle) Street Address and/or Mailing Address City State Zip Home Telephone Number Business Telephone Number Cellular Telephone Number Date you can start work Salary Desired Do you have a High School Diploma or GED? YesNo POSITION INFORMATION Check all that you are willing to work Hours: Full TimePart Time DaysEvenings SwingGraveyardWeekends Status: RegularTemporary Are you authorized to work in the U.S. on an unrestricted basis?YesNo Have you ever been convicted of a felony? (Convictions will not necessarily disqualify an applicant for employment.YesNo If yes, explain: Have you been told the essential functions of the job or have you been viewed a copy of the job description listing the essential functions of the job? YesNo Can you perform these essential functions of the job with or without reasonable accommodation? YesNo QUALIFICATIONS Please list any education or training you feel relates to the position applied for that would help you perform the work, such as schools, colleges,degrees, vocational or technical programs, and military training. School Name Degree Address/City/State SPECIAL SKILLS List any special skills or experience that you feel would help you in the position that you are applying for (leadership, organizations/teams, etc. REFERENCES Please list three professional references not related to you, with full name, address, phone number, and relationship. If you don’t have threeprofessional references, then list personal, unrelated references. Name Address/City/State Phone Relationship WORK HISTORY Start with your present or most recent employment and work back. Use separate sheet if necessary. (INCLUDE PAID AND UNPAID POSITIONS) Job Title #1 Start Date (mo/day/yr) End Date (mo/day/yr) Company Name Supervisor’s Name Phone Number City State Zip Duties: Reason for Leaving Starting Salary Ending Salary May we contact your present employer? YesNoN/A Job Title #2 Start Date (mo/day/yr) End Date (mo/day/yr) Company Name Supervisor’s Name Phone Number City State Zip Duties: Reason for Leaving Starting Salary Ending Salary Job Title #3 Start Date (mo/day/yr) End Date (mo/day/yr) Company Name Supervisor’s Name Phone Number City State Zip Duties: Reason for Leaving Starting Salary Ending Salary I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the Employer to make an investigation of any of the facts set forth in this application and release the Employer from any liability. The employer may contact any listed references on this application. I acknowledge and understand that the company is an “at will” employer. Therefore, any employee (regular, temporary, or other type of category employee) may resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or without cause, with or without notice to the other party. Applicant Signature Date Please leave this field empty.